Every finding on record at Eldora Specialty Care

Based on clinical record review, facility investigation review, staff interviews and policy review, the facility failed to protect residents from verbal and physical abuse by a staff member for 3 of 3 residents reviewed for abuse (Residents #1, #5, #6). The facility reported a census of 36 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS identified Resident #1 required substantial or maximal assistance with showering and bathing and depended on staff for tub or shower transfers. The MDS included diagnoses of hypertension (high blood pressure), non-Alzheimer's dementia (mental decline), unspecified dementia with other behavioral disturbance (confusion with behaviors), and senile degeneration of the brain (brain tissue wasting). The MDS documented Resident #1 received hospice care (end-of-life care) during the stay. Resident #1's Care Plan with a target date of [DATE] revealed Resident #1 exhibited aggressive behavior with Activities of Daily Living (ADLs) which included combativeness with staff during care or repositioning. The Care Plan documented Resident #1 would hit the staff, yell out, and use foul language. The Care Plan directed the following interventions: Allow Resident #1 opportunities to make choices and participate in cares- [DATE]Approach Resident #1 with a calm and quiet demeanor- [DATE]Staff to talk to Resident #1 in a calm voice when behavior occurred as disruptive- [DATE]Staff to reapproach with a different staff person- [DATE]Encourage Resident #1 to reposition to a recliner after the lunch meal - [DATE]Staff to offer shower prior to the lunch meal because Resident #1 can get anxious as the day proceeds- [DATE]Staff to complete shower quickly because Resident #1 does not like to stay in the shower or have peri care completed. Resident #1 can get combative with showers and staff may need an extra person in the bathing area to use distraction while the other staff member completes the bathing tasks quickly and timely- [DATE] A handwritten Internal Investigation Witness Statement completed by Staff B, Certified Nursing Assistant (CNA), dated [DATE] at 1:30 PM documented that Staff B and Staff C, CNA, assisted Staff A, CNA/Certified Medication Aide (CMA), with showering Resident #1. The statement indicated Resident #1 resisted the shower due to a dislike of showers. Staff A bent down to wash Resident #1 when Resident #1 grabbed Staff A's chest. Staff A yelled at Resident #1, stating, you will not do this to me, grabbed Resident #1's right wrist, and aggressively pushed it into Resident #1's chest. Resident #1 yelled that it hurt and screamed that Staff A broke her arm. Later during the shower, Staff A bent down to apply Resident #1's Tubi grips (elastic support bandages), and Resident #1 grabbed the hair bun on top of Staff A's head. Staff B tried to release Resident #1's hand from Staff A's hair. Staff A slapped Resident #1's hands, yelled again, and held Resident #1's hands against Resident #1's chest until the shower finished. When getting out of the shower chair, Staff A told Resident #1, if you want to get out of here, then you better stand up on your own. Staff A then proceeded to tell Resident #1 that she tried to act nice but she'd choose to act mean by lifting Resident #1 out of the chair instead. Staff A told Staff B that she acted mean because she engaged in a fight with her mother and children. The statement documented that staff reported the incident to the Administration on [DATE] at 3:00 PM. Review of the Clinical Record lacked documentation showing that staff reported the allegation of abuse to Resident #1's Attending Physician or family on [DATE]. A review of the facility document titled Self Reports revealed the facility did not file an abuse allegation with the Iowa Department of Inspections and Appeals (DIAL) on [DATE] or notify law enforcement officials of the allegations. On [DATE] at 12:54 PM Staff A reported Resident #1 didn't like her baths and called staff names. Staff A stated Resident #1 called them every name in the book. Staff A stated she, Staff B, and Staff C got Resident #1 onto the shower chair. Staff A stated Staff B intended to leave, but staff kept two aides in the shower room with Resident #1 when things appeared iffy. Staff A stated they started showering Resident #1. Staff A stated Staff B washed Resident #1's body and Staff A washed her hair. Staff A stated Resident #1 started swinging right after Staff A finished washing her hair. Staff A stated she initially took the hits. Staff A stated Resident #1 grabbed her shirt and bra, pulled them down, and also grabbed her pants and pulled them down. Staff A stated she maneuvered her thumbs up, placed her fingers around Resident #1's wrists, and pushed Resident #1's hands up onto Resident #1's chest. Staff A stated Staff B had to finish washing the front, so Staff A held Resident #1's hands to let Staff B finish without getting hit. Staff A stated she previously worked at a group home where a child acted out severely. Staff A stated she learned a safe maneuver to keep herself and the other person safe. Staff A stated she didn't clench down or provide any force, and used the maneuver as a last resort. When asked to demonstrate the maneuver, Staff A wrapped her middle finger and thumb around both of the interviewer's wrists and brought the arms up to the chest. Staff A stated she previously used this maneuver when Resident #1 experienced behavioral issues. Staff A stated she didn't press hard, squeeze, or use force, but acted to keep herself and the other person safe. On [DATE] at 2:10 PM the Director of Nursing (DON) and the acting Administrator received notification of an abuse allegation involving Resident #1 during a shower on [DATE]. The DON reported Staff B brought the issue to her attention because Staff B thought Resident #1's bath could've gone differently. The DON stated Staff C also witnessed the care. The DON stated that after speaking with Staff C, the facility management felt Staff A defended herself. The DON stated Resident #1 acted very combatively and pulled at Staff A's shirt and bra. The DON stated the facility provided education on how to work with aggressive residents. The DON stated the previous Administrator talked to the Corporate Office, and they didn't complete a self-report to DIAL. On [DATE] at 2:30 PM the acting Administrator reported that staff didn't report an abuse allegation to the facility. The acting Administrator stated the reported concerns related to a combative resident and a staff member defending herself during a shower. The acting Administrator stated [DATE] marked the first time an abuse allegation came to their attention. The acting Administrator stated the facility would complete a self-report, conduct an investigation, and suspend Staff A according to facility policy. On [DATE] at 4:03 PM Staff B reported she trained Staff C, and the day marked Staff C's first day at the facility. Staff B stated she went to assist Staff A with giving a shower to Resident #1. Staff B stated Resident #1 routinely combated staff and didn't like showers. Staff B stated the experience didn't seem too bad if staff talked Resident #1 through it and stayed calm. Staff B stated Staff A and she assisted Resident #1 to the shower chair, and Staff C grabbed the wheelchair and placed the shower chair underneath Resident #1. Staff B stated Staff A bent down in front of Resident #1 while washing her, and Resident #1 hit and grabbed Staff A in the chest. Staff B stated Staff A screamed at Resident #1, stating, you are not going to be doing this to me, this is unacceptable and you are going to stop. Staff B stated Staff A's tone didn't seem okay. Staff B stated Staff A grabbed Resident #1's wrists and pushed them to her chest. Staff B stated Resident #1 said, you are hurting me, you are breaking my arm. Staff B stated that for the remainder of the shower, Resident #1 commented that her arm felt broken and that she felt hurt. Staff B stated later, when applying Resident #1's Tubi grips, Resident #1 grabbed Staff A's hair bun on top of her head. Staff B stated that action set Staff A off again. Staff B stated Staff A grabbed Resident #1's forearms and pushed them very aggressively against her chest, which caused the shower chair to move backward. Staff B reported she intervened and suggested that either Staff A or she hold Resident #1's hands, or Staff A could step back from providing care. Staff B reported she finished getting Resident #1 dressed. Staff B stated Staff A told Resident #1, you are going to have to stand up or you're not gonna get out of the chair. Staff B stated Staff A and she helped Resident #1 get out of the chair. Staff B stated the shower ended around 2:00 PM, and the charge nurse appeared busy, so Staff B went to the DON. Staff B stated the DON got upset and told her she interpreted things wrong because she possessed a calmer personality. Staff B stated they called the Administrator, and she filled out a witness form. Staff B stated the Administrator and the DON stated they had too much occurring in their personal lives and refused to move forward with the report, noting they couldn't keep finding people to cover Staff A's shifts. Staff B stated that day, Staff A said she acted mean to the residents and didn't want to be at work because she engaged in a fight with her mother and children. Staff B stated she believed Staff A knew what she did and felt like Staff A took her anger out. On [DATE] at 6:10 PM Staff C reported she felt uncomfortable during the shower with Resident #1. Staff C stated Resident #1 acted aggressively, didn't want a shower, and punched and hit staff. Staff C stated Staff A aggressively held Resident #1's arms down and screamed in her face. Staff C stated Staff A held Resident #1's wrists up against her chest. Staff C stated Resident #1 cursed and said, I am going to kill you. Staff C stated Resident #1 tried to break loose. Staff C stated she didn't think any resident deserved treatment in that manner. Staff C stated staff should step away if a resident acted combatively. Staff C stated the transfer seemed rough initially, and Resident #1 clearly didn't want a bath from the start. Staff C stated residents hold a right to refuse a bath. Staff C stated she felt uncomfortable and just stood there because she didn't know the resident or the staff. On [DATE] at 9:43 PM Staff D, Licensed Practical Nurse (LPN), reported she heard about the incident with Resident #1 in the shower room after it occurred. Staff D stated Staff B came out of the DON's office sobbing. Staff D stated she asked Staff B what happened, and Staff B reported she faced trouble for reporting the incident as required. Staff D stated Staff B told her the DON had personal things to complete outside of work, and now the DON had to stay. The Complaint/Incident Investigation Report documented the facility filed a self-report on [DATE] at 4:25 PM. The incident summary documented the interviewer reported an abuse allegation to the interdisciplinary team. The corrective actions documented on the report included the staff member suspended, allegation reported, and investigation to follow, along with the primary care physician, family, and hospice made aware of the allegations. On [DATE] at 2:40 PM Staff E, previous Administrator, reported Staff B came to the DON's office while Staff E walked inside. Staff E stated Staff B reported she didn't like the way Staff A performed Resident #1's shower. Staff E stated Staff B reported Staff A briefly held Resident #1's wrists to prevent getting struck by Resident #1. Staff E stated Staff A reported Resident #1 acted combatively and left her with no alternatives. Staff E stated Staff A implemented a protective intervention to prevent getting hit. Staff E stated leadership decided to provide additional training on how to react to combative residents. Staff E stated they didn't complete a self-report because they held no suspicion of abuse, neglect, or misappropriation. Staff E stated Staff A put an intervention in place to prevent Resident #1 from hitting her. On [DATE] at 10:25 AM Resident #1 rested in bed. Resident #1 stated she didn't like baths and then uttered multiple unintelligible words. Resident #1 commented that she felt tired. On [DATE] at 12:45 PM Staff B stated she reported an allegation of physical abuse regarding Staff A and Resident #1 to Staff E and the DON. Staff B stated that when she went to the office to report her concerns, the DON explicitly called the incident abuse. Staff B stated the DON appeared ready to take immediate action. Staff B stated the situation changed after leadership spoke with the other staff. Staff B reported the DON stated she had too many personal issues and couldn't find coverage for Staff A. Staff B stated the DON claimed they didn't think anything happened and refused to move forward with the report. On [DATE] at 3:15 PM Staff B reported that when Resident #1 held her hand in Staff A's hair bun, Staff B tried to remove Resident #1's hand, but the process took a minute. Staff B stated Staff A became frustrated and yelled at Resident #1. When asked about the slap to the hand, Staff B stated Staff A used a slap motion to grab Resident #1's hand. Staff B stated Staff A ripped Resident #1's hand out of her hair. Staff B stated Staff A then grabbed Resident #1's hands and pushed them to her chest. Staff B stated Resident #1 screamed and said something similar to the first time, you're hurting me. Staff B stated a difference existed between sternness and acting mean. Staff B stated Staff A moved far past the point of sternness and acted mean. Staff B stated she witnessed a stern voice with other residents, but this situation differed and appeared more aggressive. A review of Resident #1's tasks revealed Staff A documented a completed shower or bath on [DATE] and [DATE]. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS identified Resident #5 maintained independence with bed mobility, transfers, and ambulation up to 150 feet. The MDS included diagnoses of hypertension (high blood pressure), hyperlipidemia (high cholesterol), and non-Alzheimer's dementia (mental decline). Resident #5's Care Plan with a target date of [DATE] revealed Resident #5 experienced behavioral problems. The Care Plan documented Resident #5 would often hit the doors to try to get them to open, yelling that she wanted out. In addition, she would hit and scratch the staff. The Care Plan directed the following interventions: Activity staff to visit with Resident #5 and provide diversional activities- [DATE]Staff to anticipate and meet Resident #5's needs- [DATE]Staff not to argue with Resident #5- [DATE] The Progress Note dated [DATE] at 10:34 AM documented Staff A reported Resident #5 hit Staff A in the back. An Internal Investigation Witness Statement completed by Staff F, CNA/CMA, dated [DATE] at 10:45 AM documented Staff F went back to the Chronic Confusion or Dementing Illness (CCDI) (severe memory loss) unit to assist Staff A. While Staff F stood in the unit, Staff A told Staff F, Resident #5 punched me in the back and I turned around and grabbed her right arm and told her you are not going to touch me'. Staff F documented that when she left the unit, she reported the incident to the charge nurse, the DON, and the Administrator. An Internal Investigation Witness Statement completed by Staff G, Registered Nurse (RN), dated [DATE] at 11:00 AM documented Staff F notified Staff G that Staff A told her Resident #5 punched her in the back, and she turned around, grabbed Resident #5, and said, Do not hit me. In addition, the statement included documentation that at 10:30 AM, Staff A told Staff G and another nurse that Resident #5 punched her, but didn't state she grabbed Resident #5. Ten minutes later, Staff A used a radio to ask the nurse if she could give Resident #5 Tylenol (pain reliever) for a hurt shoulder. On [DATE] at 9:08 PM Staff F stated she reported a concern regarding Staff A a couple of weeks ago. Staff F stated she didn't know the exact date, but the incident occurred on a Monday during the first shift around mid-morning. Staff F stated she went back to the dementia unit, and Staff A told her Resident #5 hit her in the back. Staff F stated Staff A explained that she turned around, grabbed Resident #5's arm, and said you are not going to touch me. Staff F stated she went and reported the incident to Staff G. Staff F stated Staff G stated they needed to report it to the DON and the Administrator. Staff F stated the DON and Staff E stood in the office together. Staff F stated that when they reported the concern, leadership didn't perceive it well. Staff F stated the DON appeared very upset that they reported it. Staff F reported she intended to leave early around 11:00 AM, but the DON told her she could no longer leave and had to stay to cover the remainder of Staff A's shift. Staff F reported she stayed and finished Staff A's shift. Staff F stated Staff A remained in the office for a short time and then went home. Staff F stated Staff A held a scheduled day off the next day and returned to work on Wednesday. On [DATE] at 1:55 PM the DON stated she received a report from Staff F and Staff G. The DON stated Staff A left for the day, and Staff F worked in the unit because someone needed to cover the area. The DON stated Staff E and she notified the Regional Consultant and the Human Resources director and obtained written statements. The DON stated she directed a staff member to assess Resident #5. The DON stated Staff A faced separation from the unit instead of suspension and held an original schedule to remain off until [DATE]. The DON stated that after speaking with Human Resources and the consultant, she assigned dementia training to Staff A, who completed the training on [DATE]. The DON stated that after reviewing staff statements, they didn't report the incident to DIAL. On [DATE] at 2:40 PM Staff E reported that a few weeks ago, staff reported Resident #5 became combative with Staff A when no one else stood around. Staff E stated Staff A reported Resident #5 punched her in the back when she stood next to the medication cart. Staff E stated she didn't exactly remember what occurred or what staff said. Staff E stated Staff A said something like please don't do that. Staff E stated she didn't recall Staff A touching or grabbing Resident #5. Staff E stated they held no concerns regarding how Staff A responded to Resident #5. Staff E stated Staff A appeared more shaken up about getting hit in the back. Staff E stated they decided to give Staff A tools on how to deal with difficult behaviors and handle the situation. Staff E stated Staff A worked fairly often in the CCDI unit and frequently took a beating from the residents, noting it happened to her a good amount of the time. On [DATE] at 3:00 PM Staff A reported she worked in the unit, and report notes indicated Resident #5 would try to use her shoulder to get out the door. Staff A stated that after breakfast, Resident #5 tried to leave through the main doors. Staff A stated Resident #5 seemed pretty easily redirected. Staff A stated she stood at the medication cart trying to document when Resident #5 walked back from the main door. Staff A stated she saw Resident #5 walk up behind her out of the corner of her eye and hit her in the middle of the back. Staff A stated she turned and told Resident #5 not to hit her, noting she hadn't acted mean or rude to her. Staff A stated Resident #5 did or said something that made her think Resident #5 needed to use the bathroom. Staff A stated she held out her hand, Resident #5 grabbed it, and they walked down to her room to use the bathroom. Staff A stated that when Resident #5 stood in the bathroom, Staff A radioed for a nurse to come back to the unit. Staff A stated that after Resident #5 finished in the bathroom, she asked Resident #5 if she liked to read books. Staff A stated Resident #5 took her hand again, and they walked down to the closet to look at the books. Staff A stated Staff G and another nurse both came back to the unit. Staff A stated she reported to Staff G that Resident #5 hit her. Staff A stated she reported it so it could get documented. Staff A stated Resident #5 complained of right shoulder pain, so she notified the nurse and received permission to give her Tylenol. Staff A stated the only time she touched Resident #5 occurred when she held out her hand to walk with her. Staff A stated she didn't grab Resident #5's arm after Resident #5 hit her, and she didn't tell anyone that. Review of the facility document titled Self Reports revealed the facility did not file an allegation of abuse to DIAL on [DATE] and/or notify law enforcement of the allegations. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #6 required partial or moderate assistance with bed mobility, all transfers, and ambulation up to 150 feet. The MDS included diagnoses of hypertension (high blood pressure), diabetes mellitus (high blood sugar), hip fracture (broken hip), non-Alzheimer's dementia (mental decline), anxiety disorder (severe worry), and depression (severe sadness). Resident #6's Care Plan with a target date of [DATE] revealed Resident #6 experienced a history of emotional trauma because her daughter died this past January. The Care Plan documented Resident #6 had a recliner in her room that she would sit in as an alternate positioning device. On [DATE] at 9:27 PM Staff F reported that another incident involving Staff A and Resident #6 occurred on the same day as the incident with Resident #5. Staff F stated Resident #6 reported to Staff E that Staff A acted very rude and mean to the point of making her cry twice. Staff F stated she believed the issue involved a recliner. Staff F stated she watched Resident #6 go into Staff E's office to report it. On [DATE] at 9:43 PM Staff D reported that about a week and a half ago, Resident #6 told her at supper that Staff A left her in tears over her recliner. Staff D stated Staff A told Resident #6 to quit moving the chair. Staff D stated staff inspected the chair and found an electrical issue. Staff D stated she told Resident #6 to go and talk to Staff E about the issue with Staff A. Staff D stated Resident #6 appeared alert and oriented to person, place, time, and situation, and her BIMS score showed a 15. On [DATE] at 10:15 AM Resident #6 reported Staff A flew off the handle when she got stuck in her recliner chair. Resident #6 stated her chair didn't work right. Resident #6 stated the night before, Staff A got under the chair and fixed a loose wire. Resident #6 stated the next morning, the chair kept moving up. Resident #6 stated she held onto the tray table to prevent herself from sliding out. Resident #6 stated she pushed the button for help. Resident #6 reported Staff A came in and scolded her over and over. Resident #6 reported Staff A stated she told her not to use the recliner and they wouldn't find themselves in the situation if she had listened. Resident #6 stated she felt like staff treated her like a little kid. Resident #6 reported she had been crying a lot since her daughter's passing in January. Resident #6 stated Staff A triggered the crying. Resident #6 stated that at breakfast, she told some tablemates and a couple of nurses, and they suggested talking to Staff E. Resident #6 stated she went and spoke to Staff E, and Staff E appeared apologetic. Resident #6 stated Staff E asked her if Staff A used foul language. Resident #6 stated Staff A didn't use foul language that day, but she previously heard her use foul language around others. When asked if she felt abused, Resident #6 stated she didn't experience physical abuse but felt verbally abused by Staff A's words. Resident #6 stated Staff A scolded her hard. Resident #6 stated she didn't see Staff A for a couple of days after. Resident #6 stated when she saw her in the hall, they wouldn't speak. Resident #6 stated eventually leadership assigned Staff A to her area, and they had to try to trust each other again. Resident #6 stated she proceeded with caution. Resident #6 stated everything had gone okay since then, noting leadership hadn't assigned Staff A to her area very much. On [DATE] at 11:35 AM Staff H reported Resident #6 and Staff A do not get along very well. Staff H stated she stood in the room when the recliner didn't work. Staff H stated Staff A told Resident #6 that the wires were all messed up and that Resident #6 pulled on them, which upset Resident #6. Staff H stated she felt it was a normal thing to say because chairs experience wear and tear. Staff H stated she believed Resident #6 took the comment wrong. Staff H stated Staff A's wording can seem very strong, but she didn't think she meant it maliciously. On [DATE] at 2:40 PM Staff E stated the only concern Resident #6 brought to her attention involved Resident #6 moving to Wisconsin. Staff E stated Resident #6 didn't come to her office or speak to her about any concerns regarding her recliner or Staff A, noting she would've recalled that conversation. On [DATE] at 3:00 PM Staff A reported she hadn't been aware of any concerns with Resident #6 until today. Staff A stated the new Administrator called her and asked about the recliner. Staff A reported she assisted Resident #6 to the recliner after lunch. Staff A stated the control didn't work. Staff A stated she checked the plug and cable and saw tape around the cord. Staff A stated she wiggled it, and the remote started working. Staff A stated Resident #6 took a nap, and later before supper, the call light stood on. Staff A stated Staff H and she answered the call light. Staff A stated that when they walked into the room, the chair moved all the way up and Resident #6 looked like she stood up. Staff A stated she walked around the chair to turn the call light off. Staff A stated she asked Resident #6 if she could put the chair down a little bit because it scared her, and Resident #6 responded she would if she could. Staff A reported the bedside table got caught underneath the recliner. Staff A stated she mentioned the bedside table to Resident #6, and Resident #6 stated the table had nothing to do with it. Staff A stated Resident #6 used a loud tone, appeared upset, and displayed sharpness in her voice, though she didn't yell. Staff A stated she remembered the cord and tried to wiggle it. Staff A stated one could tell the cord got pulled because the stickiness from the tape showed. Staff A stated she made a comment to Staff H about the cord getting pulled, and Resident #6 got upset, stating you're always accusing me. Staff A stated she stayed quiet and completed the care. Staff A stated as soon as Resident #6 sat safely in her wheelchair, she left Staff H with Resident #6. Staff A stated Resident #6 didn't forget things easily. Staff A stated she avoided Resident #6 for the next couple of days and asked the other aides to answer her call light to let her cool down. Staff A stated she assisted Resident #6 with rehab and placed her on the bike, and they chatted the entire time, so she believed things had blown over. When asked if any crying occurred, Staff A replied no, stating Resident #6 tore her up with her tongue. On [DATE] at 9:38 AM the Acting Administrator reported he expected the following actions when staff reported an abuse allegation: Staff must report allegations or suspicions of abuse to the DON or Administrator immediately.Separate, suspend, and investigate.Witnesses or recipients of allegations must provide clear, factual, and detailed descriptions of what they observed or heard.Facility leadership obtains statements from other parties.Staff completes a skin audit on the victim.The Administrator or DON reports the incident to DIAL as regulations require. On [DATE] at 9:49 AM the Acting Administrator reported he expected law enforcement to be notified in relation to an abuse report. The Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy dated [DATE] directed facility management to report all accounts of resident abuse, neglect, exploitation, or theft or misappropriation of resident property to local, state, and federal agencies, and thoroughly investigate the claims.

Based on clinical record review, staff interviews and policy review, the facility failed to notify the Physician and family of an allegation of abuse for 2 of 2 resident reviewed (Resident #1 and #5). The facility reported a census of 36 residents.Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. The MDS identified Resident #1 required substantial or maximal assistance with showering and bathing and depended on staff for tub or shower transfers. The MDS included diagnoses of hypertension (high blood pressure), non-Alzheimer's dementia (mental decline), unspecified dementia with other behavioral disturbance (confusion with behaviors), and senile degeneration of the brain (brain tissue wasting). The MDS documented Resident #1 received hospice care (end-of-life care) during the stay. A handwritten Internal Investigation Witness Statement completed by Certified Nursing Assistant (CNA) Staff B dated 6/4/26 at 1:30 PM documented that Staff B and CNA Staff C assisted Staff A, CNA/CMA (Certified Medication Aide) with showering Resident #1. The statement indicated Resident #1 became combative due to a dislike of showers. Staff A bent down to wash Resident #1 when Resident #1 grabbed Staff A in the chest. Staff A yelled at Resident #1, stating, you will not do this to me, and then grabbed her right wrist and aggressively pushed it into Resident #1's chest. Resident #1 yelled that it hurt and that Staff A contracted her arm or broke her arm. Later during the shower, when Staff A bent down to apply Resident #1's Tubi grips (elastic support bandages), Resident #1 grabbed the hair bun on top of Staff A's head. Staff B tried to release Resident #1's hand from Staff A's hair when Staff A slapped her hands, yelled again, then held her hands against her chest until the shower finished. When getting out of the shower chair, Staff A told Resident #1, if you want to get out of here, then you better stand up on your own. Staff A then proceeded to tell Resident #1 that she tried to be nice and she'd act mean by lifting her out of the chair instead. Staff A reported to Staff B that she acted mean because she engaged in a fight with her mother and children. The statement documented that Staff B reported the incident to the Administration on 6/4/26 at 3:00 PM. A review of the Clinical Record lacked documentation showing that staff reported the allegation of abuse to Resident #1's Attending Physician or family on 6/4/26. On 6/11/26 at 9:49 AM, the Administrator reported that he expected staff to notify the doctor and family in relation to an abuse report. On 6/11/26 at 10:30 AM, the Director of Nursing (DON) reported that Resident #1's family and hospice knew about her behaviors and medication changes on 6/4/26. She stated that staff notified Resident #1's physician and family of the allegations on 6/8/26. The Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy dated April 2021 directed facility management to thoroughly investigate and report all claims of resident abuse, neglect, exploitation, or theft of resident property to local, state, and federal agencies. The policy instructed the Administrator or the individual making the allegation to immediately report suspicions to:The state licensing or certification agency responsible for surveying the facilityThe local or state ombudsmanThe resident's representativeAdult protective servicesLaw enforcement officials,The resident's attending physicianThe facility medical director. 2. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. The MDS identified Resident #5 maintained independence with bed mobility, transfers, and ambulation up to 150 feet. The MDS included diagnoses of hypertension (high blood pressure), hyperlipidemia (high cholesterol), and non-Alzheimer's dementia (progressive brain decline). A handwritten Internal Investigation Witness Statement completed by Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) Staff F dated 5/18/26 at 10:45 AM documented that Staff F went back to the Chronic Confusion or Dementing Illness (CCDI) unit to assist Staff A, CNA/CMA. While Staff F stood in the unit, Staff A stated to Staff F, Resident #5 punched them in the back and they turned around and grabbed her right arm and told her they're not going to touch them. Staff F documented that when she left the unit, she reported the incident to the charge nurse, Director of Nursing (DON), and Administrator. A review of the Clinical Record lacked documentation showing that staff reported the allegation of abuse to Resident #5's Attending Physician or family on 5/18/26. On 6/11/26 at 10:30 AM, the DON reported she didn't recall staff reporting anything on 5/18/26 to Resident #5's family or Attending Physician.

Based on staff interviews, facility investigation review, clinical record review and policy review the facility failed to notify DIAL (Department of inspection, appeals and licensing) and Law Enforcement of an alleged verbal and physical abuse for Resident #1 that occurred on 6/4/26 at approximately 1:30 PM in a timely manner. The CNA (Certified Nursing Assistant) reported she told the DON (Director of Nursing) and Administrator of the allegations of abuse at 3 PM on 6/4/26. The facility reported the incident to DIAL on 6/8/26 at 4:25 PM after DIAL entered the building and reported an allegation of abuse. In addition, the facility failed to report an allegation of physical abuse for Resident #5 that occurred on 5/18/26 at approximately 10:30 AM. The facility reported a census of 36 residents. Findings include:1. A handwritten Internal Investigation Witness Statement completed by Staff B, Certified Nursing Assistant (CNA), dated 6/4/26 at 1:30 PM, documented Staff B and Staff C, Certified Nursing Assistant (CNA), assisted Staff A, Certified Nursing Assistant/Certified Medication Aide (CNA/CMA), give Resident #1 a shower. The statement indicated Resident #1 resisted the shower and exhibited combative behavior because she didn't like showers. Staff A bent down to wash Resident #1, and Resident #1 grabbed Staff A's chest. Staff A yelled at Resident #1, stating, you will not do this to me, grabbed Resident #1's right wrist, and aggressively pushed it into Resident #1's chest. Resident #1 yelled that it hurt and that Staff A broke her arm. Later during the shower, Staff A bent down to apply Resident #1's Tubi grips (elastic support bandages), and Resident #1 grabbed the hair bun on top of Staff A's head. Staff B tried to release Resident #1's hand from Staff A's hair. Staff A slapped Resident #1's hands, yelled again, and held Resident #1's hands against Resident #1's chest until the shower ended. When Resident #1 moved out of the shower chair, Staff A told Resident #1, if you want to get out of here, then you better stand up on your own. Staff A then told Resident #1 that she tried to act nice but she'd choose to act mean by lifting Resident #1 out of the chair instead. Staff A told Staff B that she acted mean because she engaged in a fight with her mother and children that day. The statement documented that staff reported the incident to the Administration on 6/4/26 at 3:00 PM. A review of the facility document titled Self Reports revealed the facility didn't file an abuse allegation with the Department of Inspections and Appeals (DIAL) on 6/4/26 or notify law enforcement officials of the allegations. On 6/8/26 at 2:10 PM, the Director of Nursing (DON) and the acting Administrator received notification of an abuse allegation involving Resident #1 during a shower on 6/4/26. The DON reported that Staff B brought the issue to her attention, stating she thought Resident #1's bath could've gone differently. She stated that Staff C also witnessed the shower. The DON said that after speaking with Staff C, the facility management felt Staff A defended herself. She noted that Resident #1 exhibited combative behaviors and pulled at Staff A's shirt and bra. She stated the facility provided education on how to handle aggressive residents. The DON explained that the previous Administrator talked to the Corporate Office, and they didn't complete a self-report to DIAL. On 6/8/26 at 2:30 PM, the acting Administrator reported that staff didn't report an abuse allegation to the facility. He stated that the reported concerns only related to a combative resident and Staff A defending herself during a shower. He stated that 6/8/26 marked the first time an abuse allegation came to his attention. He stated the facility would complete a self-report, conduct an investigation, and suspend Staff A according to facility policy. The Complaint/Incident Investigation Report documented that the facility filed a self-report on 6/8/26 at 4:25 PM. The incident summary documented an abuse allegation received by the interdisciplinary team. The corrective actions listed on the report included suspending the staff member, reporting the allegation, initiating an investigation, and notifying the primary care physician, family, and hospice provider of the allegations. On 6/9/26 at 2:40 PM, Staff E, the previous Administrator, reported that Staff B entered the DON's office while Staff E walked inside. She stated Staff B expressed dissatisfaction with how Staff A performed Resident #1's shower. She said Staff B reported that Staff A briefly held Resident #1's wrists to avoid a strike from Resident #1. She stated Staff A reported that Resident #1 acted combatively and that she couldn't do anything else. Staff E stated Staff A implemented a protective intervention to avoid getting hit. Staff E noted that facility leadership decided to provide additional training on how to handle aggressive residents. Staff E stated they didn't complete a self-report because they held no suspicion of abuse, neglect, or misappropriation. She reiterated that Staff A used an intervention to prevent Resident #1 from hitting her. On 6/11/26 at 12:45 PM, Staff B stated she reported an allegation of physician abuse regarding Staff A and Resident #1 to Staff E and the DON. Staff B stated that when she reported her concerns in the office, the DON explicitly called it abuse. She said the DON appeared ready to take immediate action. She stated that the situation changed after leadership spoke with other staff. Staff B reported that the DON cited too many personal issues and an inability to find coverage for Staff A. She said the DON claimed they didn't think anything happened and refused to move forward with the report. On 6/11/26 at 9:38 AM, the acting Administrator reported that he expected the following actions when staff reported an abuse allegation:Staff must report allegations or suspicions of abuse to the DON or Administrator immediately.Separate, suspend, and investigate.Witnesses or recipients of allegations must provide clear, factual, and detailed descriptions of what they observed or heard.Facility leadership obtains statements from other parties.Staff completes a skin audit on the victim.The Administrator or DON reports the incident to DIAL as regulations require. On 6/11/26 at 9:49 AM, the acting Administrator reported that he expected staff to notify law enforcement in relation to an abuse report. The Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy revised April 2021 instructed staff to report all accounts of resident abuse, neglect, exploitation, or theft of resident property to local, state, and federal agencies. It required facility management to thoroughly investigate and report the findings of all investigations. The policy directed the administrator or the individual making the allegation to immediately report suspicions to the following individuals or agencies:The state licensing or certification agency responsible for surveying and licensing the facility;The local or state ombudsman;The resident's representative;Adult protective services;Law enforcement officials;Resident's attending physician;The facility medical director. 2. A handwritten Internal Investigation Witness Statement completed by Staff F, Certified Nursing Assistant/Certified Medication Aide (CNA/CMA), dated 5/18/26 at 10:45 AM, documented that Staff F went back to the Chronic Confusion or Dementing Illness (CCDI) (severe memory loss) unit to assist Staff A. While Staff F stood in the unit, Staff A told Staff F, Resident #5 punched me in the back and I turned around and grabbed her right arm and told her 'You are not going to touch me'. Staff F documented that upon leaving the unit, she reported the incident to the charge nurse, DON, and Administrator. A review of the facility document titled Self Reports revealed that the facility didn't file an abuse allegation with DIAL on 5/18/26 or notify law enforcement of the allegations. On 6/9/26 at 1:55 PM, the DON stated she received a report from Staff F and Staff G, Registered Nurse (RN). She noted that Staff A left for the day and Staff F worked in the unit because someone needed to cover the area. She said that Staff E and she notified the Regional Consultant and the Human Resources director and obtained written statements. The DON stated she directed a staff member to assess Resident #5. She stated the facility separated Staff A instead of suspending her, and Staff A held an original schedule to remain off until 5/20/26. She said that after consulting with Human Resources and the consultant, she assigned dementia training to Staff A, who completed the training on 5/19/26. She stated that after reviewing staff statements, they didn't report the incident to DIAL.

Based on clinical record review, staff interview and policy review, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 resident reviewed with a new mental health diagnosis (Resident #1). The facility reported a census of 35 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS included diagnoses of medically complex conditions, non-Alzheimer's dementia, depression, bipolar disorder and major depressive disorder. The indicated Resident #1 took an antipsychotic, antidepressant and antianxiety medication during the lookback period. The Care Plan Focus revised 6/2/25 indicated Resident #1 had behavior problems related to diagnoses of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety directed staff. The Interventions directed to administer behavior medications as ordered by the physician, assist in selection of appropriate coping mechanism, encourage to express feelings appropriately, and explain all procedures before starting. The clinical record review revealed Resident #1 had a diagnosis effective 11/17/23 of bipolar disorder. The clinical record review further revealed they didn't have a Level II PASRR evaluation submitted after receiving the bipolar diagnosis. During an interview on 12/10/25 at 12:45 PM, the Director of Nursing (DON), acknowledged Resident #1 had an active diagnosis of bipolar disorder effective 11/17/23, which remained as an active diagnosis since that time. The DON acknowledged the MDS effective 1/17/24 included the diagnosis of bipolar disorder and each subsequent MDS included this diagnosis. The DON stated an expectation to submit a Level II PASRR with a new diagnosis and acknowledged a new diagnosis of bipolar disorder would qualify for a new PASRR. She acknowledged she didn't submit a Level II PASRR for Resident #1 after the diagnosis of bipolar disorder. Review of the facility policy admission Criteria, revised March 2019, documented the facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a mental disorder (MD), intellectual disorder (ID) or related disorders (RD). If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process.

Based on clinical record review, resident interview, staff interview and policy review, the facility failed to assist 1 of 1 resident (Resident #10) in obtaining routine dental care. The facility reported a census of 35 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions, heart failure, anxiety disorder, depression and bipolar disorder. The MDS didn't indicate Resident #10 had dentures. The Care Plan Focus initiated 5/2/24 related to Activities of Daily Living (ADL's) included the following InterventionsResident #10 ate independently with set upResident #10 needed partial assistance of 1 for oral hygiene. During an interview on 12/8/25 at 1:30 PM, Resident #10 stated she didn't have any upper or lower teeth, advising all of her teeth were removed several years ago. Resident #10 stated she didn't have dentures and voiced a desire to facility staff to have a dental appointment to discuss dentures. Resident #10 stated she wanted dentures and had been waiting for an appointment to get dentures. She added she waited for a long time for an appointment. Resident #10 stated the facility Social Worker (SW) helped her, but she didn't have an appointment scheduled and didn't see a dentist since her admission to the facility in May of 2024. The clinical record review lacked documentation regarding dental services or dental appointments for Resident #10. The clinical record listed Resident #10 had Medicaid funding. During an interview on 12/9/25 at 1:04 PM, Staff B, Social Services, stated Resident #10 had Medicaid funding. Staff B acknowledged the resident asked for a dental appointment to get fitted for dentures and expressed a desire to have dentures. Staff B stated a dental company comes to the facility to provide dental services for residents, however Resident #10 has not had dental services from this company or any other dental provider since her admission to the facility last year. Staff B stated a dental appointment had not been made for Resident #10, the resident had not received dental care since admission or since she asked to see if she could get dentures. Staff B could not recall specifically when Resident #10 asked for a dental appointment. Staff B stated Resident #10 inquired from her again yesterday about dentures and wanted to follow up with getting dentures. Staff B located an email dated 6/11/25 from the dental company that comes to the facility. The email had attachments for treatment authorization and fee for services. Staff B stated the email came around the time Resident #10 first asked for dentures. Staff B stated she didn't know what happened to the forms and said she didn't have any other documentation to show she took any additional steps to assist Resident #10 in setting up an appointment for dental care. During an interview on 12/10/25 at 12:30 PM, the Administrator stated she didn't know what steps Staff B took to set up dental care for Resident #10. During an interview on 12/10/25 at 1:30 PM, the Administrator stated Resident #10 advised her of her conversations with Staff B with regard to dentures and stated she would like to have dentures. The Administrator stated Staff B could not find additional documentation since June 2025 that she took any additional steps to set up dental care for Resident #10 until yesterday. The Administrator stated the facility expected to provide prompt dental services for Resident #10 when she requested the services. The Administrator acknowledged the facility didn't promptly provide or assist the resident with dental needs. Review of the facility policy Dental Services, revised December 2016, documented routine and 24-hour emergency dental services are provided to our residents through:a. A contract agreement with a licensed dentist that comes to the facility monthly.b. Referral to the resident's personal dentist.c. Referral to community dentists; ord. Referral to other health care organizations that provide dental services.The Social Services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible.

Based on observation, staff interviews and policy review, the facility failed to implement enhanced barrier precautions (EBP) while administering medication via a peg (feeding) tube for 1 of 2 residents reviewed for EBP (Resident #3). The facility reported a census of 35 residents. Findings include The Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a diagnosis of malignant neoplasm (cancer) of head, face and neck. The MDS reflected Resident #3 had a feeding tube and depended on staff to eat. The Care Plan revised 11/17/25 indicated Resident #3 had a peg tube. The Intervention directed staff to give medications via the peg tube. Review of Physician Orders for Resident #3 revealed an order for EBP due to a peg tube and a tracheostomy stoma (a surgical opening used for breathing instead of through the mouth or nose) effective 11/14/25. Review of the December 2025 Medication Administration Record (MAR) for Resident #3 revealed an order for Oxycodone (narcotic pain medication) 5 milligrams (mg) every 6 hours for pain as needed (PRN) via the peg tube. During an observation on 12/10/25 at 11:15 AM, observed Staff A, Licensed Practical Nurse (LPN) administer Resident #3's as needed 5 mg Oxycodone via Resident #3's peg tube. Staff A failed to apply personal protective equipment (PPE) during the administration. During an interview on 12/10/25 at 1:00 PM, Staff A acknowledged Resident #3 had been on EBP and she didn't apply PPE during administration of their pain medication. Review of facility policy titled, Enhanced Barrier Precautions, revised 12/10/25 revealed PPE for enhanced barrier precautions is necessary when performing high-contact care activities including device care or use of feeding tubes. During an interview on 12/10/25 at 1:15 PM, the Director of Nursing (DON) revealed she expected EBP to be implemented while staff administered medication to a resident via a feeding tube.

Based on clinical record review and staff interview, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed with a new mental health diagnosis (Resident #24). The facility reported a census of 35 residents. Findings include: Resident #24's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included a diagnosis of bipolar disorder. Resident #24 received antipsychotic medications during the lookback period. The Care Plan Focus revised 9/5/24 reflected Resident #24 had a behavior problem, refused to be checked and changed when wet, he would seek out women, he would pace up and down the halls. The Care Plan Goal indicated Resident #24 wouldn't have a negative outcome from the behaviors. Resident #24's Medical Diagnosis reviewed on 12/11/24 included a diagnosis of bipolar disorder effective 10/2/23. Resident #24's clinical record review revealed a negative Level 1 PASRR screening completed 7/31/23. The Level 1 PASRR documented the mental health conditions for Resident #24 as depression and altered mental status. The clinical record lacked a Level II PASRR evaluation submission following the new mental health diagnosis of bipolar disorder effective 10/2/23. Resident #24's December 2024 Medication Administration Record (MAR) included an order started 6/11/24 for aripiprazole (antipsychotic) 5 milligrams (MG) 1 tablet by mouth 1 time a day related to bipolar disorder. On 12/11/24 at 8:54 AM, the Director of Nursing (DON) reported the facility didn't complete a Level II PASSR evaluation for Resident #24 because the new diagnosis of bipolar disorder became effective 10/2/23. During a follow-up interview on 12/11/24 at 10:00 AM, the DON acknowledged the facility didn't complete a Level II PASSR with Resident #24's diagnosis of bipolar disorder. The DON added the facility didn't have a policy or protocol regarding the completion of PASRRs as they followed the regulations.

Based on record review and staff interview, the facility failed to complete a significant change following admission to hospice care for 1 of 2 residents reviewed (Resident #5). The facility reported a census of 36 residents. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] for Resident #5 documented a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating severe cognitive impairment. The MDS documented the resident admitted to the facility 7/25/17 with the most recent reentry date of 6/10/22 from the hospital. The MDS documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further documented the resident received hospice care in the last 14 days. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised 7/7/22 revealed Resident #5 had chosen to receive hospice care. Review of facility policy titled, Change in a Resident's Condition or Status, revised February 2021, revealed if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current Omnibus Budget Reconciliation Act (OBRA) regulations governing resident assessments and is outlined in the MDS Resident Assessment Instument (RAI) manual. Clinical record review revealed a significant change had not been completed following the admission to hospice care. During an interview 11/10/22 at 11:52 AM, the Director of Nursing (DON) acknowledged a significant change had not been completed following Resident #5's admission to hospice care.

Based on observations, facility policy review and staff interviews, the facility failed to ensure supervision of residents during administration of medication and safe transfer assistance for 4 of 6 residents reviewed (Resident's #9, #11, #19 and #32). The facility reported a census of 34 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had diagnoses of diabetes mellitus (DM), malnutrition and asthma. The MDS revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The MDS further revealed Resident #19 required one person physical assist locomotion on and off the unit, dressing and toilet use. The Care Plan revised on 11/4/20 revealed Resident #19 used safety devices with a goal to remain safe in her environment. Observation on 6/22/21 at 9:00 AM revealed Resident #19 had a medication cup filled with medications left on her bedside tray table. Resident #19 was taking medications with no supervision. At 9:04 AM Resident #19 was still taking medications with no one watching. On 6/22/21 at 9:04 AM, Resident #19 was observed administering medication in her room without supervision. Resident #19 stated Staff L, Licensed Practical Nurse (LPN) always leaves her medications with her because she was with it enough and all the nurse's leave medication with me in my room except one that doesn't trust me. Observed six medications in the medication cup. Resident #19 revealed she had had more medications but she had already taken some of them and you're lucky you didn't come in here earlier because the potassium pill is so big I had to choke it down. On 6/22/21 at 9:06 AM, Staff L, LPN revealed she had left the medication with Resident #19 in her room as she had an order in place stating she can take medication unsupervised. Review of Physician Orders did not indicate Resident #19 had an order in place to self-administer medication while in the facility. During interview on 6/22/21 at 9:11 AM the Director of Nursing (DON) stated Resident #19 does not have an assessment for self-medication. A review of the Medication Administration Audit Report on 6/23/21 at 1:58 PM revealed Staff I, Licensed Practical Nurse (LPN), documented the administration of Resident #19's medications for 6/22/21 at 8:54 AM. Facility policy dated 1/2015, titled Medications Administration, revealed to assure each resident received the proper medications at the correct time as ordered by their physician, administer the medication, observe for the act of swallowing and observe resident for any adverse drug reaction. 2. Review of the MDS assessment dated [DATE] revealed Resident #11 had diagnoses of [CONDITION(S)] (CVA), [CONDITION(S)] and hypertension. The MDS revealed Resident #11 had a BIMS of 13 out of 15 which indicated intact cognition. The MDS further revealed Resident #11 required set-up help with eating and one person physical assist with transfers, walking and dressing. During observation on 6/22/21 at 12:39 PM, noted half a bottle of TUMS sitting on Resident #11's night stand next to her bed. Resident #11 revealed her previous physician recommended she take TUMS for the additional vitamins. Observation on 6/23/21 at 1:01 PM, half a bottle of TUMS remained on Resident #11's night stand next to her bed. Review of Physician Orders did not indicate Resident #11 had an order in place to self-administer medication while in the facility. On 6/23/21 at 2:35 PM notified the Director of Nursing (DON) the resident had half bottle of TUMS on her night stand. Resident #11 informed the DON she took the TUMS when the facility didn't have any available at the facility and she had the TUMS since she admitted . The DON removed the TUMS and informed Resident #11 she would try to get an order for her to have the TUMS in her room. During interview on 6/23/21 at 11:10 AM, the DON acknowledged medications should not be left with a resident without supervision without an order to self-administer medication. 3. The MDS assessment dated [DATE] for Resident # 9 documented diagnoses of dementia, [CONDITION(S)] disorder (a mental illness that can affect your thoughts, mood and behavior) and [CONDITION(S)] (underactive thyroid). The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 6/21/21 at 12:24 p.m., observation of a medication cup with several medications including orange pills was noted on her lunch tray sitting to the left of the resident's recliner in her room. No nursing staff observed in the room or hallway outside of the resident's room. 4. The Annual Minimum Data Set (MDS) with reference date of 4/15/20 documented Resident#32 had diagnoses including [CONDITION(S)], stroke, cognitive communication deficit, and dementia. The MDS documented the resident had a BIMS score of 6 out of 15, which indicated severely impaired cognitive skills. The MDS documented the resident could sometimes understand, and sometimes make concrete requests. The resident had difficulty focusing attention. The MDS documented the resident required extensive assistance of one staff member for transfers, walking in his room, and toilet use. The Care Plan revealed the resident had a focus area of potential for falls secondary to impaired balance, visual impairment, and had a history of falls initiated on 4/13/18. The Care Plan included an intervention dated 11/2/18 that showed the resident was to have assist of 2 staff and walker for ambulation. A Witnessed Fall Report dated 5/30/20 with time of 7:50 p.m., documented as follows; This nurse down center hall way passing medication, certified nurses aide (CNA) called this nurse to the residents room as the resident had been lowered to the floor. Upon entering the room the nurse observed the resident sitting on the floor beside his bed with legs bent up. Resident assisted up with two staff and with a gait belt to the bed. Noted the resident had a 5.5 centimeter by 4.5 centimeter abrasion to the outer right knee area. The area had been cleansed with wound cleanser and left open to the air. No rotation or shortening noted to the residents legs. Pedal pulses palpable. Vitals completed. Immediate action taken post fall had been documented as follows; the resident would be transferred by two staff when going to bed at bedtime with a gait belt. The Fall Report documented predisposing situation factors happened during the transfer, the resident did not have on proper footwear (gripper socks), and a gait belt had not been used during the transfer. Witness to the fall had been documented as Staff K, CNA. The person documented as preparing the report had been Staff A, Registered Nurse. An Employee Coaching Worksheet dated 5/30/20 documented Staff A, Registered Nurse (RN) had coached Staff K, CNA to use a gait belt on residents when transferring whether to bed, or bathroom, or just to the wheelchair, and even when walking a resident. Staff A, RN, and Staff K both signed the Coaching document. The Nursing Guidelines and Procedure Manual dated 1/2015 edition contained a policy titled Gait Belts (for use in ambulation and transfer). The policy documented gait belts should be used by all staff, to allow for easier handling of residents which should help to avoid injuries both to residents and staff. The Guidelines were documented as follows: 1. Each staff member will have a gait belt readily available for use, when on duty. 2. Provide instructions to the resident. 3. Apply the belt around the resident's waist snug enough to eliminate the possibility of sliding up on the ribs. 4. Assist the resident to the edge or the chair/bed/surface, with both feet flat on the floor. 5. Staff are to use proper body mechanics: Bend and lift with your knees and not your back, Keep your back straight at all times. 6. Bring the resident to a standing position by grasping the with both hands, while remaining upright yourself. 7. Use the gait belt during ambulation to stabilize the resident by grasping the belt firmly in the middle of the resident's back. 8. Walk along side and slightly behind the resident, while holding onto the belt. 9. If a resident begins to lose their balance, draw resident close to you ease him/her down with your hold of the gait belt. this protects you and the resident from head or body injury. Call for assistance and do not move the resident until he/she has been assessed by the nurse. A Case Summary with submitted date 6/14/20 by the facility Administrator documented the company policy had been that all resident transfers of any type require a gait belt for the safety of the resident. The Administrator documented that during an interview Staff K reported she had been oriented to the use of a gait belt, and she said, Unless it's right there I don't use it. I have one floating around here somewhere. The Administrator documented the interview had been witnessed by her and the Nurse Consultant. The Orientation Checklist: Nursing Assistant dated 5/17/19 for Staff K, CNA documented she had been instructed on assist ambulation with use of a gait belt, and resident transfers. The Nurses Note dated 5/31/20 at 6:00 a.m. documented the resident had yelled out in pain when his right leg had been moved, staff assisted the resident to sit at the side of the bed, with maximum assist of two staff. The resident had not been able to bear weight, and the resident complained of pain to the right upper leg, the staff then laid him back down in bed. An x-ray report dated 5/31/20 documented the resident had a slightly displaced fracture of the right hip, and a orthopedic consultation had been recommended. The x-ray report documented the resident had a fight femur (upper leg bone) demonstrate a slightly displaced subcapital fracture. The Nurses Note dated 5/31/20 at 1:35 p.m. documented new orders for the resident to be sent by ambulance to the emergency room . The Nurses Note dated 6/5/20 at 1:35 p.m., documented the resident had returned to the facility after a right hip repair surgery. On 6/22/21 at 10:45 a.m. Staff H, CNA, reported that during a one person assist transfer the gait belt is put on the resident before the transfer. On 6/22/21 at 10:45 a.m. noted Staff H, CNA had a gait belt on her waist. On 6/22/21 at 10:50 a.m., Staff D, Certified Medication Aide (CMA) reported that during a transfer gait belts are used for all two person and one person transfers. On 6/22/21 at 10:50 a.m. noted Staff D, had a gait belt around her waist. On 6/22/21 at 11:03 a.m. Staff G, CMA reported Resident#32 could be, a one assist or even two assist at the time of his fall on 5/30/20, and always use a gait belt with any transfers. Staff G reported staff had been provided education to wear the gait belts if not in use. On 06/22/21 at 3:00 p.m. Staff I, Licensed Practical Nurse (LPN) the resident had been a transfer of one to two people depending on his status, for example in the morning it maybe ok to use one staff member, and then two in the afternoon maybe needed for safety. Staff I reported that gait belts should be use with all transfers. On 6/22/21 at 3:33 p.m., Staff A, RN reported Resident#32 had been a transfer of one with a gait belt, at the time of his fall on 5/30/20. Staff A, RN reported she heard Staff K, CNA yell her name for help, she entered the residents room and the resident was on the floor. Staff K did not use a gait belt when she transferred the resident, and no other staff had been in the room. Staff A reported there had been no gait belt in the room, on the resident, or on Staff K, CNA. Staff A, RN stated the gait belt could have helped with the fall and injury. Staff A, LPN reported that after the fall had been assessed by the management team there had been in services about gait belt use. On 6/22/21 at 12:03 p.m. the Director of Nursing reported gait belts should be use for all transfers. On 6/23/21 at 12:22 p.m. Staff B, reported gait belts should always be used for transfer that require one or two staff members to assist a resident. On 6/23/21 at 12:33 p.m. Staff C, RN reported that on 5/30/20 the resident would have been a one to two person assist with transfers, and a gait belt should always be used for those type of transfers. .

Based on clinical record review, observation, staff interview, and resident interview, the facility failed to provide privacy of a body during personal cares for 1 out of 1 sampled residents observed for cares, (Resident #30) and failed to provide privacy by not knocking on the door before entering the room for 6 of 9 residents. The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 30 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the Brief Interview for Mental Status (BIMS) was not completed. On 6/22/21 at 2:34 p.m., Staff M, Certified Nursing Assistant (CNA) entered Resident # 30's room and assisted her with getting a drink of water and repositioning her head. Staff M, CNA pulled Resident #30's gown up and pulled the sheet down exposing the resident's incontinence brief and upper thighs which were visible from the doorway. Staff M, CNA did not close the privacy curtain or the door to the room. When Staff M, CNA completed her check she pulled Resident #30's gown back down and sheet back over the resident covering her. 2. Observation on 6/23/21 at 2:17 p.m., revealed Staff N, Housekeeping staff, bringing clothing from the laundry room to the resident's rooms. Staff N, Housekeeping staff observed entering 9 different resident's rooms without knocking and waiting for a response. Six of these rooms were occupied by residents. Review of the facility policy titled Resident Rights- general guidelines June 2011 edition revealed all staff should be encouraged and reminded to knock before entering a resident's room and to wait for a response. All staff should be encouraged and reminded to use the privacy curtain during personal cares. Interview on 6/23/21 at 3:17 p.m., with the Director of Nursing revealed she expects the staff to provide privacy at all times when providing care to any resident. She also revealed it is the expectation of all staff to knock on residents doors and wait for a response before entering.

Based on observations, staff interview, and record review, the facility failed to provide appropriate infection control standards for 11 residents of 11 residents observed. The facility reported a census of 35 residents. Findings include: 1. Observation on 6/22/21 at 2:39 p.m., revealed Staff N, housekeeping staff, delivering laundry to rooms in hallway A. Laundry cart with clean clothing was sitting in the hallway uncovered. Staff N, housekeeping staff, came out of the room and proceeded to push the cart down the hallway uncovered to the next room. Staff N, housekeeping staff, took the clothing off of the rack and placed them under their arm against their uniform and walked into the room and placed residents' clothing into the closet. 2. Observation on 6/23/21 at 2:17 p.m., revealed Staff N, housekeeping staff, delivered laundry to the rooms in hallway B and C. Laundry cart with clean clothing covered from the top down exposing the bottom of the residents' clothing hanging on the bar in the hallway at the beginning of the clothing being passed. Staff N, housekeeping staff uncovered half of the clothing and left uncovered walking down the hallway. Staff N, housekeeping staff, was observed 8 times holding clothing up against their uniform while delivering clothing. Staff N, housekeeping staff was observed to have their mask below their nose while delivering laundry to 4 separate rooms before pulling the mask up and did not perform hand hygiene after pulling the mask up. 3. Observation on 6/23/21 at 2:34 p.m., Staff O, Certified Nursing Assistant (CNA) observed with mask below nose passing ice water to residents in hallway B. Staff O, CNA, observed passing water to 3 different resident rooms before pulling her mask up and performing hand hygiene. During interview on 6/23/21 at 3:17 p.m., the Director of Nursing(DON) stated that all staff are expected to hold linens away from their scrubs, that is an infection control issue as they eat and work in their scrubs. The DON revealed she would expect all staff to wear their masks above their nose. Review of facility policy titled Preventing Spread of Infection, March 2013 edition revealed transport carts with clean linens are to be completely covered during transport. Review of facility policy titled Linens, March 2013 edition revealed facility staff will handle, store, process and transport linens so as to prevent the spread of infection. Review of the facility policy titled COVID-19 Visitation policy updated April 1, 2021 revealed core principles of COVID-19 infection prevention included face covering or mask covering mouth and nose and appropriate staff use of personal protective equipment (PPE). Centers for Disease Control and Prevention website titled, Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, visited 6/24/21 and updated 2/23/21, revealed Healthcare Personnel (HCP) should wear well-fitting source control (use of well-fitting face masks to cover a person ' s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing) at all times while they are in the healthcare facility. The website further revealed, if worn properly a facemask helps block respiratory secretions produced by the wearer from contaminating other persons and surfaces.

Based on staff interviews, staff record reviews, and facility policy the facility failed to report a possible allegation of abuse to the facility Administrator, and the Department of Inspections and Appeals within the proper time period for one of one allegation of abuse from a resident about a staff member, (Resident#32). The facility reported a resident census of 34. Findings included: The Dependent Adult Abuse Policy dated 11/2019 edition documented under the page title Timely Abuse Reporting as follows; All allegations of resident abuse, neglect, exploitation, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegations of resident abuse shall be reported to the Iowa Department of Inspections and Appeals no later than two hours after the allegation is made. All allegations of resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, no later than two hours after the allegation is made, if the events that cause the allegation result in serious bodily injury. On 6/23/21 at 12:22 p.m. Staff B Licensed Practical Nurse (LPN) reported that she did hear Resident#32 tell the ambulance staff on 5/31/20 about being pushed down. Staff B, LPN did not report the residents allegation of being pushed down to the administrative staff as abuse due to the resident being of poor cognitive status. On 6/23/21 at 12:33 p.m., Staff C Registered Nurse (RN) reported that on 6/1/20 during shift report Staff A RN told her Resident #32 reported being pushed down on 5/31/20 to Staff B, Licensed Practical Nurse and the ambulance staff, when being picked up to go to the hospital. Staff C, reported she had talked with the Administrator about the accusation on 6/1/20, but the Administrator told her she did not know about it. Staff C, RN reported the Administrator immediately started an investigation after being aware of the accusation. Staff C, RN reported she had been written up for not reporting within 2 hours, of learning about the possible abuse. On 6/23/21 at 1:12 p.m. the Director of Nursing (DON) reported she did not know about the accusation that Resident #32 had voiced to the Ambulance staff, and the facility staff, until 6/1/20. The DON reported the resident had stated to the Ambulance staff and facility staff that he had been pushed down by facility staff. The DON reported the staff involved had been disciplined for not reporting possible abuse within two hours The Nurses Note dated 5/31/20 at 1:35 p.m. documented new orders for Resident#32 to be sent by ambulance to the emergency room . The Nurses Note dated 5/31/20 at 2:30 p.m. documented the ambulance had been at the facility to transport Resident #32 to the hospital. The Nurses Notes for the date 5/31/20 lacked documentation that the staff had reported any resident accusation about being pushed down by a staff member when he fell . A Corrective Action Form dated 6/2/20 contained a verbal warning to Staff B, LPN. The description of infraction had been documented as follows; you heard a resident tell an ambulance tech that he was pushed. Corrective Action: documented as follows; Any allegation made by a resident should be reported to the Administrator or DON immediately, abuse allegations require a two hour reporting window. Don't hesitate to call anytime. A Corrective Action Form dated 6/2/20 contained a verbal warning to Staff A, RN. The description of infraction had been documented as follows; You were told by another nurse that a resident had fallen and the resident had told the ambulance tech that he was pushed. Corrective Action: documented as follows; Any allegation made by a resident should be reported to the Administrator or DON immediately. Abuse allegation require a two hour reporting window. Don't hesitate to anytime day or night. A Corrective Action Form dated 6/2/20 contained a verbal warning to Staff C, RN. The description of infraction had been documented as follows: Your were told by another nurse that a resident had fallen and the resident told the ambulance tech that he was pushed. Corrective Action documented as follows: Any allegation made by a resident should be reported to the Administrator or DON immediately. Abuse allegations require a two hour reporting window. Don't hesitate to call anytime night or day. An x-ray report dated 5/31/20 documented Resident#32 had a slightly displaced fracture of the right hip, and that a orthopedic consultation had been recommended. An x-ray report dated 5/31/20 documented Resident#32 had a fight femur (upper leg bone) demonstrate a slightly displaced subcapital fracture.

Based on resident observations, clinical record review and staff interviews the facility failed to develop care plans to address resident's oxygen usage for 2 of 2 sampled residents (Resident #4 and #30). The facility reported a census of 34 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 4 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. Review of the MDS dated [DATE] revealed Resident # 4 used oxygen. Review of Resident #4's Care Plan, dated 6/1/21, on 6/22/21 at 10:28 a.m., lacked any documentation of oxygen usage. On 6/23/21 at 3:44 p.m., the MDS Nurse brought a copy of Resident #4's Care Plan for oxygen therapy with date initiated 6/23/21. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #30 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the Brief Interview for Mental Status (BIMS) was not completed. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Care Plan, dated 5/11/21, on 6/22/21 at 8:20 a.m., lacked any documentation of oxygen usage. On 6/23/21 at 3:44 p.m., the MDS nurse brought a copy of Resident #30's Care Plan for oxygen therapy with date initiated 6/22/21. Interview on 6/23/21 at 3:17 p.m., with the Director of Nursing revealed she expects all resident's care plans are to be up to date and they are to include oxygen usage. Review of facility policy titled Oxygen Administration January 2015 edition revealed resident care plan: identify problem, establish goals with resident input, and develop approaches with responsible disciplines identified. Review of facility policy titled Care Plan Process January 2015 edition revealed the care plan will be an ongoing reflection of the current treatment plan. Additions and deletions can be made on the plan of care (with resident approval) without holding a care plan conference, as long as the change does not constitute a permanent, significant change.

Based on clinical record review, resident and staff interview, the facility failed to provide advance notice of care planning conferences for one of eight residents reviewed (Resident #10) The facility census was 30 residents. Findings include: A Minimum data set (MDS) assessment dated [DATE], documented Resident #10 had [DIAGNOSES REDACTED]. During interview on 8/5/19 at 10:22 a.m., the resident reported she was not invited to her care plan conferences. During interview on 8/6/19 at 10:15 a.m., the Director of Nursing (DON) stated residents are usually invited by verbal contact and family contacted by telephone or letter with the documentation of attendance or declining to attend being noted in the care plan conference summary in each residents progress notes. Clinical record lacked documentation of the resident attending or declining to attend care plan conferences on 5/22/19, 2/27/19, 8/29/18 and 5/23/18. During interview on 8/7/19 at 8:27 a.m., the DON confirmed she was unable to locate any documentation the resident was invited to the care conferences. During interview on 8/7/19 at 8:30 a.m., the Administrator expected residents to be invited to care conferences.

Based on observation, clinical record review and resident and staff interview, the facility failed to ensure two of five residents reviewed received proper grooming. (Resident #1 & #5 ) The facility census was 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 11 of 15, indicating moderately impaired cognition. A Care Plan with a problem onset dated 1/29/10, indicated the resident required assistance with his/her ADL's. Observation on 11/2/16 at 1:45 p.m., revealed the resident had whiskers present on his/her chin approximately 1/4 inches long. Observation on 11/8/16 at 12:46 p.m., revealed the resident with the same whiskers present on his/her chin. During interview on 11/9/16 at 1:10 p.m., the resident indicated he/she shaved every day prior to admission to the facility. 2. The MDS assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. A Care Plan indicated the resident required minimal assistance with ADL's. Approaches included one person to assist with bathing. Observation on 11/3/16 at 1:00 p.m., revealed the resident had whiskers present on his/her chin approximately 1/4 inches long. During interview at the time, the resident indicated he/she had a shower on that day and staff should have shaved them. The resident indicated he/she shaved every day prior to admission to the facility. Observation on 11/8/16 at 1:40 p.m., revealed the resident with the same whiskers present on his/her chin. During interview on 11/8/16 at 2:37 p.m., Staff B, Certified Nurse Aide, CNA indicated female residents were shaved when they received a shower. During interview on 11/9/16 at 10:10 a.m., Staff A, CNA indicated staff shaved female residents when they could get to them.

Based on clinical record review, staff and resident group interview, the facility failed to answer resident call lights in a timely manner to ensure resident needs were met. The facility census was 35 residents Findings include: 1. During group interview on 11/3/16 at 1:00 p.m., three of three resident indicated staff did not answer resident call lights in a timely manner. One resident felt the facility was short on staff as he/she utilized the clock on the wall in his/her room and he/she had to wait over one 1 hour the previous night for staff assistance. The resident stated they wanted lotion on their legs as they itched. Another resident indicated they utilized the clock on the wall in his/her room and timed his/her call light as on for over 1 hour. The resident stated recently he/she waited for 25 to 30 minutes and when no one arrived he/she ambulated to the bathroom and fell . During interview on 11/9/16 at 10:09 a.m., Staff A, Certified Nurse Aide, CNA confirmed the resident's call light as on when he/she fell . An Incident/Accident/Unusual Occurrences Form dated 10/25/16 at 8:50 a.m., documented the resident fell on the floor in the bathroom with no injury. The resident stated the call light was on but staff failed to get there soon enough. Another resident stated they had not timed the call light but felt he/she had to wait 20-25 minutes for staff assistance. Additionally, there were times staff answered the light after 20-25 minutes and he/she asked for a snack so staff left to get a snack but failed to return so he/she placed the call light on again and would wait another 20-25 minutes. During interview on 11/9/16 at 11:30 a.m., the Corporate Nurse indicated the facility failed to have a policy on call lights, however it was the expectation for staff to answer call lights within 15 minutes.

Based on observation, record review and interviews, the facility failed to ensure Resident #1 received adequate supervision to protect against hazards in the environment. Resident #1 left the dementia unit through a window without staff's knowledge and a community member observed him/her 3 blocks away from the nursing home. Staff acknowledged knowing Resident #1 had eloped from a window at a prior nursing home. Staff reported Resident #1's 15 minutes checks had not been completed at the time of the elopement as result of only one staff in the dementia unit who had been providing cares to another resident. The findings constitute an immediate jeopardy to resident's health and safety. The facility reported a census of 9 residents in the dementia unit and a total census of 30 residents. Findings include: 1. According to the MDS (Minimum Data Set) dated 4/14/2016, Resident #1 had severe impairment of cognitive skills for daily decision making, transferred and ambulated independently and had [DIAGNOSES REDACTED]. The Elopement Risk Assessment completed on 4/14/2016 documented Resident #1 had a high elopement risk. The assessment identified Resident #1 was not oriented to person, place or time and had a history of [REDACTED]. The physician's orders [REDACTED].#1 to the CCDI (dementia) unit on 2/8/2016. The Physician's progress note dated 4/14/2016 revealed Resident #1 had a previous elopement at another long term care facility prior to admission to Eldora Specialty Care. The psychiatrist letter dated 5/17/2016 revealed Resident #1 had been evaluated and determined he/she had significant memory loss related to a neurocognitive disorder due to vascular disease. The resident had intact communication skills however his/her decision making capacity was so impaired, he/she would be unable to care for his/her personal safety. The Care Plan identified Resident #1 had a history of [REDACTED]. On 2/4/2016, staff placed a STOP sign across the resident's door while in the room. The Care Plan identified Resident #1 had a potential for impaired communication secondary to dementia, and it identified the resident had exit seeking behaviors, and had a history of [REDACTED]. The care plan documented Resident #1 had been admitted at this nursing home via emergency protective services and resided on the dementia unit. The care plan also identified Resident #1 had a history of [REDACTED]. On 5/23/2016, the Care Plan added the resident had a window in his/her room did not open and directed staff to provide 15 minute checks and a laser alarm on at night while in room. On 6/2/2016 the Care Plan directed staff to have the laser alarm on at all times while in room to alert staff when out of room. On 6/3/2016 the resident moved closer to the dining room. The Nurse's Notes dated 5/23/2016 revealed the facility housekeeping and maintenance staff observed Resident #1's window screen appeared loose. Staff replaced the screen and installed locks to prevent the window from opening. Staff initiated 15 minute checks, and the resident denied attempt to exit the facility. Staff informed the Administrator. The Nurse's Notes dated 5/27/2016 revealed Resident #1 asked staff for a screwdriver to help the window rise. The Nurse's Notes dated 6/2/16 revealed staff obtained a urine sample with negative results. Staff noted the laser alarm on at all times when in room and continued 15 minute checks. The Nurse's Notes dated 6/2/16 documented at noon documented the resident had been ambulating in the hallway and looking in other resident rooms. On 6/3/16 the resident moved closer to the dining room and the nurse's station. The Nurse's Notes dated 6/28/2016 at 6:20 p.m., documented staff received a phone call from person inquiring about a resident observed outside the facility. Staff did a room to room check and were unable to locate Resident #1. A facility CNA (Certified Nurse Aide) went and returned with the resident. Staff assessed the resident and notified family and physician. The incident reported dated 6/28/16 at 6:20 p.m., revealed staff received a phone call from a person asking about a (missing resident). Staff started a search and determined Resident #1 was missing. Treatment sheet for June 2016 documented staff completed his/her wanderguard checks. The 24 Hour Resident Monitor flow sheet dated 6/27 - 6/28/2016 revealed staff failed to document observation of Resident #1 at 6:15 p.m. on 6/28/2016. The Physician Notification Fax dated 6/29/2016 informed Resident #1's physician that he/she eloped from the facility the evening prior through a window. Staff were able to redirect and return the resident to the facility. On 7/5/2016 at 3:55 p.m., the state climatologist reported on 6/28/2016 at 6:15 p.m. the area had a temperature of 75 degrees with mostly cloudy skies. During an interview on 7/6/2016 at 8:30 a.m., the employee of another nursing home (CNA) stated on 6/28/2016 a community member reported going to a ballgame at the high school and noticed Resident #1 sitting on the curb. The community member asked if they had a missing resident. When they asked if they could provide assistance, the resident asked for a ride to Hubbard. She called Eldora Specialty Care to report the incident, went to the resident and stayed until help arrived. The resident had a phone with a dead battery. The surveyor calculated the distance from the facility to the high school at 0.3 miles. During an interview on 7/7/2016 at 9:00 a.m., Resident #1 stated what the facility is doing here, isn't doing anything for me. A couple of days ago I went for a walk, got out through a window, and it was easy. They brought me back. The resident reported living at another facility prior where he/she climbed out of a window. The resident indicted he/she liked the people at the facility, did not care for the institution, and lived at the two facilities a total of 8.5 years. The resident sat in the room, in the recliner during the interview and expressed a desire to return home. On 7/6/2016 at 3:30 p.m. the DON reported Resident #1 had lived at another long term care facility, and the resident exited that facility when he/she climbed out of a window. During an interview on 7/5/2016 at 3:05 p.m. and 7/7/2016 at 10:00 a.m., Staff B, CNA reported working the night Resident #1 eloped from the facility. Staff B worked in the main area of the facility and went to the dementia unit to assist with supper at 5:30 p.m. After supper, Staff A gave two showers. At approximately 6:05 p.m., Staff B observed Resident #1 walked to his/her room and Staff B turned on the resident's laser alarm, and shut the door. Staff B took Resident #5 to the bathroom and remained with the resident. When Staff B finished assisting Resident #5, Staff A completed the showers and Staff B left the unit. The facility received a call asking if they were missing a resident. They checked the unit, and failed to locate Resident #1. Staff B observed the window screen had been removed in room #7. Staff B never heard the resident's laser alarm sound because he/she had assisted Resident #5 to the bathroom and had closed the room door and the bathroom door. If Resident #1 quickly turned off the alarm, he/she may not have been able to hear it. The resident had 15 minute checks. At times, it is difficult to complete the checks on time if you are providing cares and you are the only staff in the unit. During an interview on 7/5/2016 at 2:15 p.m., Staff A, CNA reported working in the dementia unit on 6/28/2016 from 2 - 10 p.m. From 2 - 4 the unit had one staff. At 4 o'clock p.m. the nurse or medication aide passed medication in the unit and that is when Staff A took a 30 minute break. From 4:30 - 5:30 p.m. Staff A worked alone in the unit. At 5:30 p.m. they served supper and another aide (Staff B) came to the unit to assist. When the residents finish eating, Staff B left the unit, leaving one aide to complete cares. At 8 o'clock p.m., the nurse or med aide passed medications in the unit, and Staff A went to the floor to assist staff with resident cares. At 8:30 p.m., when the nurse finished with medications, Staff A returned to the unit and the nurse left. Staff A continued to assist residents with bedtime cares. On 6/28/2016, Staff A had two resident showers to complete, so Staff B remained in the unit after supper to supervise the other residents. At approximately 6 o'clock p.m., Staff A observed Resident #1 sitting at the dining room table, when he/she took a resident to the shower room. At approximately 6:30 p.m., Staff C came to the unit and asked about Resident #1. Staff A had been toileting Resident #5 who had an alarm and could not leave the resident unattended on the toilet. Staff A observed Room #7 had a dresser placed near the window with a drawer removed and placed on the bed (Resident #7 ' s prior room). The window's screen had been removed and placed along the building. Staff A drove to the high school and found the resident with staff from another facility. The resident got in the car and they returned to the facility. When they reached the facility, the resident refused to get out of the car but finally the Administrator convinced the resident to return inside. The resident had no (physical) signs of injury. The resident asked to go to Hubbard and wore a sweater because he/she planned on being out all night. Staff A never heard the laser alarm sound, and never witnessed the resident turn off the laser alarm. On 7/7/2016 at 9:35 a.m., Staff A reported having difficulty completing the 15 minute checks on time when providing cares such as toileting or putting residents to bed. Sometimes those tasks take longer. At that time (6/28/16), Resident #5 had a chair alarm and staff had to stay with the resident while toileting. When they realized Resident #1 eloped, Staff A had been in the bathroom with Resident #5 at approximately 6:30 p.m. That night, after supper, Staff A gave two showers that took about 10 - 12 minutes each. Staff B had assisted Resident #5 to the toilet during that time. When Staff A completed the showers, Staff B returned to the floor, leaving the unit. Resident #5 again requested to go to the bathroom, so Staff A assisted the resident to the bathroom. During an interview on 7/5/2016 at 2:50 p.m., Staff C, RN (Registered Nurse) reported working on 6/28/2016 and last observed Resident #1 at approximately 5 p.m. when he/she checked the resident's wanderguard bracelet. Staff C had no observations of the resident attempting to exit the facility. At approximately 6:20 p.m., Staff C received a call from another nursing facility asking if they were missing a resident. Staff C checked the unit and saw Resident #1 had exited the facility. The resident had 15 minute checks at the time due to his/her interest in another resident. The resident had a laser alarm to alert staff when he/she left the room. During an interview on 7/5/2016 at 3:30 p.m., Staff E, Maintenance reported when Resident #1 resided in Room #7, the housekeeper observed the loose window screen. It appeared that the resident may have pushed on the screen. They replaced the screen and installed L brackets to prevent the window from rising. The window had stops in place to prevent the window from rising greater than four inches. It appeared they had been pushed in. When they moved the resident to his/her new room, Staff E moved the L brackets, too. Room #7 had been empty with the door shut since the resident moved out. When they ordered the new windows, they purposely ordered ones with stops in place. All of the windows in the unit had the stops pulled out when installed. After Resident #1 eloped, they installed L brackets on all windows in the unit. During an interview on 7/7/2016 at 9:30 a.m., Staff F, CNA, CMA (Certified Medication Aide), reported they provided 15 minute checks on one resident in the unit, Resident #1. The unit had 9 residents and currently, they had two residents that required assistance with transfers, two with laser alarms, and two with alarms. At times staff had difficulty completing the 15 minute checks on time if busy taking a resident to the bathroom. At approximately 8:15 a.m., Restorative staff came to the unit to provide exercises with a couple of residents and then left. During an interview on 7/5/2016 at 11:00 a.m., the Administrator reported when Resident #1 exited the facility shortly after supper on 6/28/2016, two staff in the unit were busy providing cares. Resident #1 had resided in Room #7 before being moved to his/her current room. The resident exited the facility through the window in Room #7. The resident pulled out the second drawer of a three drawer dresser, placed it near the window and used it as a ladder. The resident opened the window, removed the screen and placed it nearby, climbed out and shut the window. A passer-by observed the resident sitting on the ground near the high school, and reported it to the other nursing home next door. Staff from that facility went, found the resident and sat with him/her until facility staff arrived. When the resident returned, staff provided a head to toe assessment, and 1:1 supervision until L shaped brackets were installed on all windows in the dementia unit to prevent the windows from rising. The resident had no signs of injury or distress. The resident eloped at his/her prior facility. When the resident resided in Room #7, they noted he/she had tempered with the window screen so they added the L brackets to that window. When they moved the resident to his/her current room, they moved the L brackets to those windows. During an interview on 7/6/2016 at 10:30 a.m., the Director of Nursing (DON) reported the facility attempted to maintain 8 - 9 residents in the dementia unit. The facility replaced all windows within the last four years, and each window had stoppers that could be pulled out to prevent the windows from rising greater than approximately four inches. In May, housekeeping staff noted that the window screen in room #7, had been tampered with. The facility replaced the screen and added L shaped brackets to prevent the window from rising. In June, the resident moved to a room closer to the dining room. The resident had developed a romantic interest in another resident and the facility separated them, and added laser alarms to both rooms. When they moved Resident #1 to his/her current room, they removed the L brackets from the windows in room #7 and installed them on the window in his/her current room. When the resident exited the facility, he/she must have turned off the laser alarm. Staff A, CNA and Staff B, CNA were in the unit, but were busy providing resident cares at the time. No staff had knowledge of the resident turning off the laser alarm prior. The 15 minute checks log revealed staff saw Resident #1 at 6:00 p.m., no staff visualized the resident at 6:15 p.m. and staff knew the resident had exited the facility at 6:30 p.m. Staff B reported seeing the resident at 6:05 p.m. when he/she went to the room, and Staff B turned on the resident's laser alarm. After the resident eloped from the facility, they installed L brackets on all of the dementia unit windows. The facility updated Resident #1 ' s care plan on 6/28/16 and directed staff to provide 1:1 supervision (visual contact at all times) then moved to 15 minute checks once the L brackets were placed on all the windows on 6/28/16; however the facility did not increase the number of staff in the unit to provide adequate supervision for residents. On 7/7/2016 at 9:50 a.m. the DON reported at the time Resident #1 eloped from the facility on 6/28/2016, the dementia unit had three of nine residents that required assistance with transfers. Resident #5 and Resident #7 required assistance of one staff for transfers and both had bed and chair alarms. Resident # 6 required the assistance of one staff for transfers and had a floor alarm. On 7/7/16 the facility identified they would maintain 2 staff members in the unit as long as residents in the unit required more assistance with toileting/ or other ADL (activities of daily living) or increased supervision needs. The facility abated the IJ on 7/7/16 when they increased supervision to maintain two staff on the unit. The IJ was lowered from a J severity to D severity with continued monitoring of interventions.

Based on record and policy review, observations and staff interviews, the facility staff failed to follow professional procedure for documentation of medication administration and facility policy for 4 of 33 reviewed residents (Residents #8, #11, #12, and #14). The census of the facility was 33 residents. Findings include: 1. Resident #8 had a readmission date of [DATE]. The face sheet documented [DIAGNOSES REDACTED]. Review of the 2/16 Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. 2. Resident #11 had an admission date of [DATE]. The face sheet documented [DIAGNOSES REDACTED]. Review of the 2/16 MAR for Resident 11 revealed a blank space for the a.m. dose of Potassium Extended Release 10 milliequivalents (meq) (a supplement) on Sunday 2/14/16 and a blank space for [MEDICATION NAME] 6 mg (a blood thinning medication) on Tuesday 2/9/16. The physician's orders [REDACTED]. 3. Resident #12 had an admission date of [DATE]. The face sheet documented [DIAGNOSES REDACTED]. Review of the 2/16 MAR for Resident #12 revealed blank spaces for the a.m. doses of Aspirin 81 mg, [MEDICATION NAME] 30 mg, [MEDICATION NAME] 2.5 mg, [MEDICATION NAME] 10 mg (all medications for treatment of [REDACTED]. The physician's orders [REDACTED]. 4. Resident #14 had a readmission date of [DATE]. The face sheet documented [DIAGNOSES REDACTED]. Review of the 2/16 MAR for Resident #14 revealed a blank space for the 2/13 and 2/14/16 night doses of [MEDICATION NAME] Acid 250 mg (an anticonvulsant and mood stabilizer). The physician's orders [REDACTED]. The facility policy for Medications Administration dated 1/15 directed staff to record the medication given on the MAR by initialing the proper square. During interview on 2/16/16 at 3:45 p.m., the Director of Nursing (DON) reviewed the blister packs for the above mentioned medications which were not signed as given. The medications were not present. The DON there was no way to determine if the stock medications, such as the aspirin and vitamins, had actually been administered.

Based on observation, record review and staff interview, the facility failed to provide adequate and complete incontinence care for 2 of 6 residents reviewed (Resident #3 and #5). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 11/5/15 revealed Resident #5 had [DIAGNOSES REDACTED]. The assessment documented that Resident #5 had both short and long term memory problems and a moderately impaired ability for daily decision making, and relied on staff to perform hygiene due to frequent episodes of bowel and bladder incontinence. Resident #5's most current Care Plan with a goal date of 5/4/16 indicated the resident relied on staff to perform incontinence care after each incontinence episode, and monitor for skin breakdown secondary to intermittent confusion and incontinence. On 2/16/16 at 7:13 a.m., observation revealed Staff A Certified Nursing Assistant (CNA) took Resident #5 to the bathroom. Staff A removed the resident's wet disposable brief as the resident sat on the toilet. After the resident stood, Staff A began frontal incontinence care, which included Resident #5's groin areas being cleansed, but Staff A failed to cleanse Resident #5's genitalia. Next the CNA began incontinence care to Resident #5's rectal area, but failed to cleanse either the hips or buttocks. The CNA put a new disposable brief on the resident, and then pulled up his/her pants. According to the January 2015 Edition of their incontinence care policy, all soiled skin should be cleansed. During an interview on 2/17/16 at 12:30 p.m., the Director of Nursing stated that she expected staff to cleanse any skin that contacted the wet brief. 2. The MDS dated [DATE] revealed Resident #3 had [DIAGNOSES REDACTED]. The assessment documented that Resident #3 had severely impaired ability for daily decision making, and relied on staff to perform hygiene due to occasional episodes of bowel incontinence. Resident #3's most current Care Plan with a goal date of 3/10/16 indicated the resident required staff assistance to provide perineal care after each incontinent episode, and monitor for skin breakdown secondary to cognitive impairment and immobility. On 2/16/16 at 8:25 a.m., observation revealed Staff B, Certified Medication Aide (CMA), took Resident #3 to the bathroom. The facility consultant was present in the room. Staff B removed the resident's disposable brief which was soiled with bowel movement after the resident sat on the toilet. As the resident sat, Staff B began frontal incontinence care, which included Resident #3's groin areas being cleansed. Next the CMA began incontinence care to Resident #3's rectal area, but failed to cleanse either the hips or buttocks. The CMA put a new disposable brief on the resident, and then pulled up his/her pants. According to the January 2015 Edition of their incontinence care policy, all soiled skin should be cleansed. During an interview on 2/17/16 at 2:30 p.m., the facility consultant stated that she had not been in a position to observe the cares.

Based on observation, clinical record review, staff, resident and family interviews, the facility failed to employ sufficient nursing staff to ensure a safe environment in the Chronic Confusion or Dementing Illness (CCDI) unit where nine residents resided. The facility census was 30 residents. Concern was identified with five of nine residents on the CCDI unit. (Resident #1, #2, #3, #4 & #5) Findings include: 1. The admission Face Sheet dated 822/14, documented Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had long and short-term memory impairment and moderate cognitive impairment that included poor decision making skills and required cues/supervision. The MDS indicated the resident had behavioral symptoms that included hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds, not directed at others occurred one to three days. The MDS indicated the resident required staff assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing and was frequently incontinent of bowel and bladder. The plan of care problems listed included: the resident required staff assistance with cares secondary to his/her cognitive impairment and had impaired communication secondary to impaired thought process related to dementia. The resident required encouragement and assistance to participate in activities, and the resident had a history of [REDACTED]. Interventions included staff would do 15 minute checks to ensure his/her safety and other residents safety, an alarm was on his/her bedroom door at night to alert staff when resident was out of his/her bedroom, use redirection and distraction when resident was touching others or being overly helpful, the resident preferred to be around other residents and would seek out other residents and wander into other rooms, the resident enjoyed holding other people's hands. Nurse notes dated 7/27/15 at 6:35 p.m., revealed staff was summoned to the unit. The resident was seated on another resident's bed and would not move. Nurse notes dated 7/9/15 at 4:00 p.m., documented the resident had to be led out of two other resident bedrooms. Nurse notes dated 7/8/15 at 2:00 p.m. documented the resident had one incident of contact with a resident of the opposite sex. The other resident had his/her arm around this resident's waist, walking down the hall. Nurse notes dated 7/7/15 at 1:00 p.m., documented the resident was up per usual. Redirection effective when another resident asked to go into a bedroom with this resident. During interview on 9/2/15 at 12:38 p.m., Staff K, certified nurse aide, CNA stated one night at approximately 10:15 p.m., she found a resident in a bedroom of another resident of the opposite sex. Staff K assisted Resident #2 back to his/her bedroom, assisted the resident to the bathroom, changed the resident's soiled brief and assisted the resident to bed. At approximately 11:00 p.m., Staff K found Resident #2 back in the bedroom of Resident #5. Staff K again explained to Resident #2 he/she could not be in the bedroom of the resident of the opposite sex and assisted the resident back to his/her bedroom. Staff K stated this was highly unusual and she had never found Resident #2 in the bedroom of Resident #5 in the past. Staff K assisted the resident back to his/her bed and then went to care for other residents. Staff K reported about midnight a staff member came to the unit to inform her the call light in the bathroom of Resident #5 was on. Staff K went to the bedroom of Resident #5. and found the bedroom door closed. Staff K knocked and after no response opened the bedroom door. Staff K observed both residents on their sides in a spooning position. Staff K pulled back the covers and saw both residents lay naked in the bed. Staff K found the nurse just outside the unit and asked her to come to the unit. Staff K stated in the past she had found Resident #2 in a resident's bedroom of the opposite sex during the night shift. Staff K found the resident sitting in the other resident's chair in his/her bedroom. 2. The MDS assessment dated [DATE], Documented Resident #5 scored 9 on the BIMS cognitive test. The resident exhibited verbal behavioral symptoms four to six days in the seven-day assessment period. The resident exhibited other behavioral symptoms not directed toward others. The MDS indicated the resident rejected cares and wandered. The MDS documented the resident was independent with transfers, walking, dressing, eating, toilet use and personal hygiene. Nurse notes dated 7/8/15 at 2:00 p.m., documented the resident had one incident of contact with a resident of the opposite sex. Resident had his/her arm around the other resident's waist, walking down the hallway. Residents were separated. Nurse notes dated 7/14/15 at 7:00 a.m., documented the resident demanded staff fill his/her water pitcher with coffee. Staff informed resident, he/she could have a cup of coffee with refills. Resident became upset and pushed things across countertop yelling and cursing at staff. Nurse notes dated 7/17/15 at 2:00 p.m., documented the resident had harsh words with another resident. The resident was teasing the other resident. The other resident became upset. The resident teasingly put up fists to pretend to box as usual. Resident upset. Residents were separated to different areas. Nurse notes dated 7/24/15 at 4:30 p.m., documented the resident was in the dining room and was told to throw paper away. Resident called the other resident lazy and to throw his/her own paper away. Words were exchanged and an argument escalated. Both resident stated they were going to fight. Staff ushered this resident out of the CCDI unit. Nurse notes dated 7/25/15 at 1:30 p.m., documented the resident continued to get agitated with staff. Nurse notes dated 7/26/15 at 1:00 p.m., documented the resident put his/her hand on another resident's back as he/she passed the other resident in the hall. Nurse notes dated 7/28/15 at 2:00 p.m., documented removed another resident from area after resident was rubbing this resident's back, to avoid conflict. Nurse notes dated 7/28/15 at 3:00 p.m., documented the resident called another resident names, removed resident to own room. An Incident/Accident/Unusual Occurrence Form dated 7/3/15 at 11:15 p.m., indicated a nursing assistant found a resident of the opposite sex in bed with the resident. Nursing assistant reported the residents were last observed five minutes prior. During interview on 8/25/15 at 7:15 p.m., Staff D, CNA stated when Resident #2 was first admitted to the CCDI unit, he/she would transfer any resident who was in a wheelchair. During interview on 8/25/15 at 7:25 p.m. Staff E, CNA stated they found Resident #2 in the bedroom of a resident of the opposite sex. Staff E stated Resident #2 would frequently go into that resident's bedroom and stated Resident #4 would get upset with a resident of the opposite sex, Resident #3 and would call the resident a cunt, a whore and/or a slut. Staff E stated this would occur on a weekly basis. Staff E stated Resident #3 would say, Oh, you don't like me, nobody likes me. Observation on 8/25/15 at 7:25 p.m., revealed Resident #2 instructed Resident #3 to go to the nursing assistant. Resident #2 walked across the hall and entered another resident's bedroom. Staff E reported other residents did not like Resident #2 entering their bedrooms. Staff E reported Resident #2 had a sweet tooth and would go into the bedroom of Resident #1 and take his/her snacks and that upset the resident. Staff E stated they would find Resident #2 coming out of the bathroom of Resident #1 and Resident #1 would say he/she could not keep Resident #2 out of his/her bathroom. The facility placed a Velcro strip across the doorway to the bedroom of Resident #1, however Resident #2 would take the Velcro strip down and enter the bedroom. Staff E stated one staff member assigned to the CCDI unit was not always adequate to provide care and supervise the residents in the unit. Staff E stated it depended on the day and the residents. Staff E stated she was instructed to not to let Resident #2 and Resident #5 in each other's bedrooms, she was to keep them separated and she was to keep an eye on them. During interview on 8/25/15 at 10:00 p.m., Staff F, CNA stated Resident #5 was normally up and down all night long. Staff F stated he found Resident #2 and Resident #5 alone in the family lounge holding hands and seated very close on the couch. Staff F stated he kept a close eye on the two residents during the night. Staff F stated Resident #2 did not understand what was going on and he/she was very vulnerable. During interview on 8/24/15 at 7:17 p.m., Staff H, CNA stated when she worked in the CCDI she had to keep an eye on Residents #2 and Resident #5. Staff H stated it was impossible to keep an eye on them when she was in a another resident's bedroom providing care. Staff H stated Resident #2 liked to sneak across the hall in the bedroom of Resident #5. During interview on 8/24/15 at 7:20 p.m., the Administrator stated after the sexually inappropriate incident between Resident #2 and Resident #5, Resident #5 was temporarily removed from the unit and they began doing fifteen minute checks on Resident #2. The Administrator stated the facility decreased their staffing before she came to the facility in March 2015. She stated staff were educated to keep the two residents separated. She stated Resident #5 was on a waiting list to transfer to another facility. The Administrator stated it was impossible for the CCDI staff to monitor resident behaviors when they were staffed with only one staff member in the unit per shift and they were in other resident rooms providing care. Observation on 8/24/15 at 7:10 a.m., revealed one staff member in the locked CCDI unit. Observation revealed a resident standing in his/her bedroom doorway with only a very loose brief in place. The disposable brief was pulled to the side exposing the resident's perineal private area. Observation revealed it took Staff H several minutes to encourage the resident to step back and close the bedroom door. Observation revealed at 7:12 p.m., Resident #3 verbalized the need to use the bathroom. Staff H assisted the resident to his/her room/bathroom and shut the bedroom door. Observation revealed Resident #2 and Resident #5 were alone in the family room. During interview on 8/24/15 at 3:15 p.m., Staff I, CNA stated one day she was alone in the CCDI unit when she saw two residents in the dining room. Resident #4 told Resident #5 to throw away a snack wrapper. Which was nothing new. When Resident #4 wanted something done, he/she wanted it done right away. Resident #5 called Resident #4 lazy. Resident #4 stood up and told Resident #5 to call him/her lazy one more time. Resident #4 challenged Resident #5 to a fight. Staff I was in the hallway and pushed the panic button to summon other staff to the unit. The Social Service Director came into the unit and stood in the hallway with Staff I. About thirty minutes later, Resident #3 who could not hear entered the dining room. Resident #4 had a history of [REDACTED]. #3 due to he/she could not hear. Staff I heard Resident #4 call Resident #3 a [***] , a cunt and a whore several times in the past. Resident #3 began to ask Resident #4 who he/she was. Resident #4 screamed at Resident #3. Resident #4 was not being very nice. Resident #4 stood up and went to hit Resident #3. Staff I entered the dining room and attempted to come in-between the two residents when Resident #4 made contact with Resident #3 and knocked eye glasses off the resident's face. Staff I stated one day she observed Resident #2 approach Resident #5 in the dining room and ask him if he wanted a blow job. Resident #5 stated that would be nice. Resident #2 stated it was not the time nor the place. Staff I reported she had found Resident #2 a bedroom with Resident #5. Staff I stated Resident #2 would slap people on the butt. Staff I witnessed Resident #5 calling Resident #2 down to his/her bedroom. Staff I stated if you are not quick, Resident #2 would sneak into Resident #5's bedroom. Staff I stated the facility used to staff the CCDI unit with two staff on the day shift and two staff on the evening shift, but now they only have one staff member in the unit at all times. Staff I stated she can not supervise the residents when she is in a residents bedroom providing care. Staff I stated she could not call other staff members into the unit to assist her due to they are too busy on the main floor. Staff I reported they cut staffing in the CCDI unit in February 2015. Observation on 8/24/15 at 3:40 p.m., revealed one staff member in the CCDI. Observation revealed the staff member mopping a resident's bathroom with the bedroom door closed. Observation revealed Resident #4 was seated near Resident #3 in the dining room and Resident #2 and Resident #5 were seated together. During interview on 8/25/15 at 10:30 a.m., a family member stated on 8/24/15 during the noon meal, he/she observed residents eating in the CCDI dining room. Resident #2 stood up and stated he/she needed to use the bathroom and walked out of the dining room. The resident exited the dining room and walked into another resident's bedroom. Observation on 8/24/15 at 6:00 p.m., revealed one staff member and nine residents in the locked CCDI unit. The alarm sounded and a call light was on for one resident's bedroom. Staff went to the end of the hall to silence the sounding exit alarm and to assist the resident in the wheelchair. Observation revealed Resident #5 entered the dining room and sat with Resident #2. Resident #3 stood up and attempted to give his/her food to other residents. The resident with his/her call light on stated he/she needed assistance due to his/her oxygen tubing was tangled up and caught under a wheel. Observation revealed Resident #2 and Resident #5 were alone in the dining room. Staff went into a resident's room to provide care due to the resident opened his/her bedroom door and stood naked in the doorway. Continued observation revealed Resident #2 and Resident #5 remained unsupervised in the dining room. Observation revealed a dietary staff member exited the locked unit as dietary staff member exited the unit the alarm sounded. Dietary staff failed to reset the exit door alarm and the exit alarm continued to sound and the exit door remained unlocked. Observation revealed the only staff member in the unit was assisting a resident. After completing the care, staff came to the exit door and reported dietary staff left the unit and the door was open too long which triggered the alarm and therefor the door remained unlocked until the alarm was reset. Staff reset the alarm and reported being on duty since noon. Staff I pushed a crying resident up and down the unit hallway. Staff I reported the resident experienced Sun Downing every evening after supper. Staff I went into a resident's bedroom and shut the door. Resident #2 and Resident #5 remained together and unsupervised in the dining room. Resident #2 asked Resident #5 if he/she would assist Resident #3 to the bathroom. Resident #5 stated no and instructed Resident #2 to take the resident to the bathroom. Resident #2 took Resident #3 by the hand and led the resident to his/her bedroom to the bathroom. Resident #3 stated he/she needed to use the bathroom. At that time Staff I exited the other resident's bedroom. Resident #3 stated he/she needed to find where he/she placed his/her stuff. Staff I reminded the resident he/she could not go into other residents bedrooms at which time the resident agreed. Staff I reported when she was the only staff member in the unit she could not supervise the resident and provide care. Staff I stated when the resident had his/her call light on, the exit door was sounding and Resident #2 and Resident #5 were alone together, she had to prioritize where she would go. Staff I stated she could not supervise Resident #2 and Resident #5, she had to go to the resident who was attempting to exit the building and then assist the resident who came to the bedroom door naked. Observation on 8/24/15 at 6:35 p.m., revealed one resident call Staff I into his/her bedroom due to his/her toilet needed attention. Staff I went into the resident's room. Observation revealed Resident #2 and Resident #5 were alone together in the family room. At 6:40 p.m., Staff I exited the resident's bedroom and entered another resident's bedroom and closed the door. Resident #2 and Resident #5 remained alone and unsupervised in the family room. At 6:42 p.m., Staff I asked a resident in a wheelchair if he/she was ready to go to bed. The resident stated yes. Staff I assisted the resident into his/her bedroom and closed the bedroom door. Resident #2 and Resident #5 remained alone together and unsupervised. At 6:47 p.m., a staff member came into the unit went into the resident's bedroom and asked Staff I if she was ready for a break. The two staff remained in the resident's bedroom with the door closed. Resident #3 joined Resident #2 and Resident #5 in the dining room. Resident #5 asked Resident #3 to leave the dining room. 3. The MDS assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident transferred and walked independently and required assistance with dressing and toilet use. The resident's Care Plan dated 7/8/15, documented the resident had difficulty expressing ideas or wants secondary to dementia with a history of aggressive and assaultive behaviors, potential for pain, [MEDICAL CONDITION] medication use due to dementia with a history of aggressive and assaultive behaviors. Approaches included: allow plenty of time to respond to conversation, provide a quiet environment for resident when discussing important issues, can best understand simple yes/no questions, encourage resident to go to room if display agitation, administer [MEDICAL CONDITION] medications as ordered, provide reorientation as needed The Care Plan Problem related to the use of [MEDICAL CONDITION] medications indicated a goal of no injury related to medication use. Approaches included: administer medications as ordered, monitor for adverse side effects, dosage reduction per pharmacy recommendations and monitor behaviors per flow sheet. Nurse notes dated 7/15/15 at 8:00 a.m., late entry for 7/14/15 at 4:30 p.m., documented the resident was in the dining room in CCDI unit and used foul language and called another resident names. The resident was loud and scared other residents. Nurse notes dated 7/16/15 at 4:30 p.m., documented the resident was in the dining room on CCDI unit and yelled profanity at another resident who asked him/her what time it was. The resident called the other resident names and threatened the resident. Nurse notes dated 7/24/15 at 4:30 p.m., documented the resident was seated at the dining room table and asked another resident to throw away a paper. The other resident told the resident to throw the paper away him/herself and called the resident lazy. The resident got upset and raised his/her voice. The situation escalated to name calling. Staff intervened. The resident's attention was then redirected to another resident near him/her. The other resident asked him/her a question. The resident began to hit the other resident. Staff removed the other resident enough so the resident's fingers went across the resident's face and knocked the glasses off his/her nose. Nurse notes dated 7/25/15 at 11:00 a.m., documented verbal aggression towards staff member as staff separated resident from another resident. The resident stated profanity. Nurse notes dated 7/26/15 at 8:00 p.m., documented staff reported the resident called another resident names. Nurse notes dated 7/27/15 at 3:13 p.m., documented when upset the resident yelled at another resident. During interview on 8/24/15 at 3:00 p.m., Resident #4 stated he/she got into it with Resident #5. The resident stated Resident #5 irritated him/her due to every thing was a crisis for Resident #5. The resident stated the other day, Resident #5 complained about pain and the resident did not believe there was anything the staff could do about the resident's pain. The resident then got into it with Resident #5 and told Resident #5 he/she would kick his/her ass. The resident stated it was hard for him/her not to swing at and hurt Resident #5. The resident stated he/she had a bad temper ever since he/she was a child. The resident stated after he/she got into it with Resident #5, Resident #3 came up to him/her and began to talk to him/her and he/she slapped the hell out of Resident #3. The resident stated he/she should not have slapped Resident #3 as it was not his/her fault and they did not deserve it. The resident stated he/she told Resident #3 to shut up. 4. The MDS assessment dated [DATE], documented Resident #3 was admitted to the nursing home on 1/27/15 and had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance with bed mobility, transfers, eating, toilet use, personal hygiene and bathing. The resident's Care Plan dated 8/19/15, identified the resident's difficulty with communication secondary to cognitive impairment, hearing impairment and dementia. Approaches included: please approach from the front in a calm, unhurried manner, allow plenty of time to answer simple yes and no questions, reorient as needed, administer medication as ordered. An approach added 7/21/15 indicated the resident frequently stated he/she was a pain in the butt and asked the same questions repeatedly every day. An approach added on 7/28/15 instructed staff to encourage activities prior to the evening meal if resident restless/wandering in other resident room or asking other residents the same questions repeatedly. Nurse notes dated 5/23/15 at 7:00 p.m., documented the resident transferred to CCDI unit. The resident was yelling at other residents and scaring them. The resident was getting too close to another resident who did not like it and agitated them. The resident accepted redirection and then did it again a few minutes later. Nurse notes dated 5/25/15 at 10:30 p.m., documented the resident kept asking another resident if they could leave and go out. Nurse notes dated 7/9/15 at 10:00 p.m., documented the resident was swearing at three other residents throughout the shift and stated he/she would slap them if they did not walk with him/her. Nurse notes dated 7/24/15 at 4:30 p.m., documented the resident was at a table in the dining room with a resident who had been yelling at another resident. The other resident swung at the resident as staff pulled the resident back, the resident's right side of face was brushed and glasses knocked off. During interview on 8/25/15 at 7:25 p.m., Staff E, CNA stated Resident #4 would get upset with Resident #3 and would call the resident a cunt, a whore and/or a slut. Staff E stated it occurred on a weekly basis. During interview on 8/24/15 at 3:15 p.m., Staff I, CNA stated Resident #4 had a history of [REDACTED].#3 due to he/she could not hear. Staff I heard Resident #4 call Resident #3 a [***] , a cunt and a whore several times in the past. During interview on 8/24/15 at 1:30 p.m., the resident stated he/she tried to be good. He/she stated one day he/she had his/her eye glasses knocked off his/her face. The resident denied the ability to recall the details of the incident. The resident stated he/she was heart broken when it happened. The resident stated his/her eye glasses meant a lot to him/her. 5. The MDS assessment dated [DATE], documented Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS documented the resident required assistance with bed mobility, dressing and bathing. During interview on 8/20/15 at 9:15 a.m., the resident and the resident's spouse stated Resident #2 and Resident #3 would come into his/her bedroom and go through his/her belongings and steal his/her belongings. The residents would come into his/her bathroom while the resident was seated on the toilet and the resident found this embarrassing. The resident stated no one would want to be seen while seated on the toilet. One day they could not find the remote to the resident's television. They informed staff who went to the bedroom of Resident #2 and found six remotes in his/her room. The resident and the resident's spouse stated the facility finally placed the Velcro stop sign across the resident's bedroom door to keep the other resident's out of his/her bedroom. The staff were great, however they could not supervise the residents all the time. During interview on 7/20/15 at 1:55 p.m., the Director of Nursing, DON stated the facility decreased staffing in January or February of 2015, due to low census. The DON stated they went from having one nurse and four aides on the day shift to one nurse and three aides and on the second shift they decreased their staffing from one nurse and four aides to one nurse and three aides. The DON stated they decreased staffing in the CCDI unit from two staff in the unit on the day shift and on the second shift to having only one staff in the unit on all three shifts.